The death of a two-year-old boy, 14 months after an x-ray failed to detect the plastic toy he had swallowed, has led to a coroner issuing a warning to senior doctors.
Kazarie Dwaah-Lyder was given the scan in February 2022 after consuming a “googly eye” imitation eyeball, but the item was not detected as it was not made of metal.
Kazarie lived for just over a year “without symptoms” until he was rushed to Great Ormond Street Hospital in April 2023, where he died.
In a Prevention of Future Death report, Mary Hassell, the senior coroner for Inner North London, questioned the lack of national guidance on children who are suspected to have swallowed non-metal objects in light of the child’s “unforeseen” death.
Soon after swallowing the plastic eyeball — a small crafting item used to imitate eyeballs — Kazarie was taken to the hospital as he was “suspected of having swallowed a plastic foreign object”. The infant, who was one at the time, underwent an x-ray and a fluoroscopy, both returning negative results.
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Kazarie was sent home and displayed no further symptoms until he was rushed to the hospital in April of the following year. The two-year-old boy died due to an upper gastrointestinal bleed and an oesophageal tear from swallowing a foreign body.
The coroner recorded a verdict of accidental death. Hassell 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.
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”.
Hassell said: “In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action.”
After his death, a GoFundMe appeal was started to support the family of Kazarie.
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The fundraiser said: “Kazarie was an amazing, smart, funny and loving little boy who had an old soul. He touched the hearts of many, and we want to give him the farewell he deserves.”