Board: Medical Board of Australia
Finding Date: 3 November 2015
Details: Inquest into the death of Summer Alice Steer by the Office of the State Coroner, Queensland Courts constituted by John Hutton, Coroner.
From time to time, a state coroner may refer a finding of an inquest to AHPRA or the Board to bring to the attention of the profession. AHPRA will publish a case summary of each referral from the coroner on its website, naming the deceased person, with the coroner’s recommendations in full. A link will also be provided to the coroner’s website. Practitioners are encouraged to access the AHPRA website at www.ahpra.gov.au to keep up to date with these cases and the coroner’s recommendations.
When the Board decides that a referral from the coroner has wide-reaching implications for practitioners, it may publish a summary of the case, and highlight particular issues relevant to the profession.
Four-year-old Summer Steer died 30 June 2013 after swallowing a two-centimetre button battery. The medical cause of Summer’s death was a haemorrhage, due to an aorta-oesophageal fistula, which was caused by the ingestion of a button battery that was lodged in her oesophagus.
Summer attended the doctors of Tewantin clinic with her mother Ms Shoesmith on 17 June 2013 with a sore stomach. Her mother had recently had giardia and a prescription for antibiotics for this was provided to Summer. This is thought to be the first indication of the ingestion of the battery.
Summer was first taken to the Noosa Private Hospital after vomiting blood on Sunday 30 June around 12.30am. She was discharged around 2am after showing no indication that her condition was anything more severe than a spontaneous blood nose. The vomiting was incorrectly attributed to epistaxis, a result of Summer swallowing the blood of the earlier nosebleed.
At 10.40am Summer was readmitted to hospital following further blood vomits. She collapsed during a blood transfusion and was then intubated and ventilated. It was during the routine post-intubation chest x-ray that the button battery was discovered.
Summer was transferred by helicopter from the Noosa Private Hospital to the Royal Children’s Hospital. On landing, she went into cardiac arrest and was raced to surgery. The surgeons located the approximate site of the aorta injury and could feel the button but were unable to access it for removal.
The source of the battery remains unknown. By the time of its discovery, the acid from the battery had created a fistula (perforation) in the oesophagus causing significant damage and blood loss during surgery. Summer was pronounced deceased at 1:45pm.
Dr Forde was of the opinion that the medical cause of Summer’s death was:
1(a) Haemorrhage, due to, or as a consequence of
1(b) Aorto-oesphageal Fistula, due to, or as a consequence of
1(c) Oesophageal Foreign Body (Battery).
The full coroners report can be read on the Queensland Courts website.
Button battery manufacturers are urged to fund and develop without delay:
Button battery manufacturers are called upon to urgently implement the Australian Competition Consumer Commission’s suggested packaging and safety warning standards for all button batteries sold in Australia. This should be reflected in the development of an industry ‘best practice guideline.
All manufacturers, distributors and retailers of products containing button batteries are called upon to:
That the ACCC:
That the Commonwealth Government implement, in conjunction with state governments, industry, and the Australian Battery Recycling Initiative:
That the Queensland Government collaborate with the button battery industry and product manufacturers, distributors and retailers to fund organisations such as the Office of Fair Trading and Kidsafe to:
That all state health departments:
That all Pediatric hospital sites:
The Royal Australian and New Zealand College of Radiologists and the Australian Institute of Radiographers are encouraged to:
The Australasian College of Emergency Medicine; Royal Australasian College of Surgeons (general paediatric surgeons and ear nose and throat surgeons); and Royal Australasian College of Physicians (Paediatricians and Paediatric Gastroenterologists) are encouraged to:
That Noosa Private Hospital (and Ramsay Health):
That the Nambour General Hospital:
That the Queensland – Ambulance Service:
That Dr Spall: