A London toddler, aged 2, died of a tear to his throat more than a year after swallowing a plastic googly eye, sparking a warning from the coroner.
Beloved Kazarie Dwaah-Lyder, from North Woolwich, was initially taken to hospital in February 2022 at the age of 16 months after it was suspected he had swallowed the tiny plastic object.
He was given an x-ray and fluoroscopy, but both failed to identify the object he had ingested.
The little boy then went without symptoms for 14 months.
But on April 26 last year he was admitted to Great Ormond Street Hospital.
A hole was discovered in his oesophagus - which connects the throat and the stomach - and he died in the early hours of the following morning.
An inquest into his death, which concluded at Poplar Coroner’s Court on February 9, deemed his death “accidental”.
In a Gofundme page set up shortly after his death, Kazarie’s mother Bianca Lyder-Wallace wrote: “Kazarie was an amazing, smart, funny and loving little boy who had an old soul, he touched the hearts of many.”
He leaves behind an older brother as well as his parents.
Coroner Mary Hassell has now issued a prevention of future deaths report, which are published by coroners when they believe an individual, organisations, or the Government can learn from a death and take action to prevent further fatalities.
Ms Hassell raised concerns over an apparent lack of national guidance for hospitals when presented with children who are thought to have swallowed small objects.
"It was suggested to me in evidence that children suspected of having swallowed a non radio opaque object such as a googly eye, whose symptoms (unlike Kazarie’s) persist, should undergo an endoscopy even if they have had a negative x-ray and fluoroscopy,” she wrote.
"I was told that there is a lack of national guidance for such a situation. I appreciate that there are multiple considerations in planning investigations, such as the risks associated with CT scanning and the risks associated with the administration of a general anaesthetic.”
But she added: “It seems that the matter would benefit from consideration at a national level."The report was sent to the British Association of Paediatric Surgeons (BAPS), Royal College of Paediatrics and Child Health (RCPCH), and Royal College of Radiologists.
The BAPS confirmed it had received the coroner’s report, and would be responding before the April 8 deadline given by the coroner.
A spokesperson added: “We were saddened to hear about this case and our thoughts go out Kazarie’s family.”
An RCPCH spokesperson said: “This is an absolutely tragic case and our thoughts go out Kazarie’s family.
“I can confirm that RCPCH has received the coroner’s report and will be responding within the timeframe stated.”
