Finding into death of Isabella Estelle Rees
Deceased
Isabella Estelle Rees
Demographics
1y, female
Date of death
2015-02-04
Finding date
2019-04-04
Cause of death
Gastrointestinal haemorrhage due to aorto-oesophageal fistula caused by lodged button battery in oesophagus
AI-generated summary
Isabella Rees, aged 14 months, presented to Sunshine Hospital ED four times over 19 days with fever, vomiting and later haematochezia. A button battery lodged in her oesophagus caused progressive caustic injury leading to aorto-oesophageal fistula and fatal gastrointestinal haemorrhage. Parents repeatedly expressed concerns about foreign body ingestion but these were not documented in medical records. The coroner found the emergency care was reasonable and appropriate given the non-specific symptoms and difficulty of diagnosing occult battery ingestion. Clinical lessons centre on recognising subtle clues suggestive of button battery ingestion, recording parental concerns systematically, and heightening clinical suspicion of battery ingestion in cases with unexplained gastrointestinal symptoms or melaena. Key failures were incomplete documentation of parental statements and lack of systematic consideration of foreign body ingestion despite explicit parental concern.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Button battery lodged in oesophagus causing caustic chemical injury
- Delayed recognition of button battery ingestion
- Non-specific presenting symptoms (fever, vomiting) attributed to urinary tract infection
- Parental concerns about foreign body ingestion not documented in medical records
- Progressive alkaline burn from battery over 19-day period
- Perforation with secondary aorto-oesophageal fistula formation
Coroner's recommendations
- Introduction of a General Safety Provision into Australian Consumer Law to prohibit unsafe consumer products containing button batteries and incentivise safe design with secure battery compartments
- Western Health should ensure the 'Call for Help' policy enabling family escalation of clinical concerns is clearly communicated to all families and staff
- Victorian Paediatric Clinical Network, Safer Care Victoria and Royal Children's Hospital develop a state-wide clinical practice guideline for assessment and management of potential button battery ingestion, incorporating QISU guideline 'Disc batteries: Who and What do I x-ray?' and promoting Victorian Poisons Information Centre as first point of contact
- Kidsafe Victoria conduct button battery awareness campaigns, particularly before public events when children may be exposed to battery-containing products
- Royal College of Physicians (Paediatrics), Royal College of General Practitioners, Australasian College for Emergency Medicine and Ambulance Victoria use this finding as educational tool to raise awareness of occult button battery ingestion and ensure inclusion in core curricula
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —