Child died a year after X-ray failed to spot swallowed 'googly eye'

A coroner has issued a warning to senior doctors after a two-year-old boy died 14 months after an x-ray failed to detect the plastic toy he had swallowed.

Kazarie Dwaah-Lyder was given the scan in February 2022 after swallowing a "googly eye" imitation eyeball, but the item was not detected as it was not metallic. 

The boy lived for more than a year "without symptoms" until he was rushed to Great Ormond Street Hospital, London, in April 2023, where he died. 

In a Prevention of Future Death report, (PFD) senior coroner for Inner North London, Mary Hassell, questioned the lack of national guidance on children suspected to have swallowed non-metal objects after the child's "unforeseen" death. 

Soon after swallowing the plastic eyeball, a small item used in craft work to imitate eyeballs, Kazarie Dwaah-Lyder was taken to hospital as he was "suspected of having swallowed a plastic foreign object." 

The boy, who was only one year old, underwent an x-ray and a fluoroscopy, both of which returned negative results. 

He was sent home and displayed no further symptoms until he was rushed to Great Ormond Street Hospital, in April 2023, where he died due to an upper gastrointestinal bleed and an oesophageal tear from swallowing a foreign body. 

The coroner recorded a verdict of accidental death and wrote to the British Association of Paediatric Surgeons, Royal College of Paediatrics and the Royal College of Radiologists, telling them "There is a lack of national guidance" for situations where objects go undetected, and children do not display symptoms. 

In the PFD, the coroner highlighted that CT scanning and giving a general anaesthetic to children were not without risks, but that "the matter would benefit from consideration at a national level." 

She added: "In my opinion, action should be taken to prevent future deaths, and I believe that you have the power to take such action."