This unfortunate child was the victim of what I term “the perfect storm.” This event represents a concatenation of circumstances, which, combined were responsible for the death of this young child. This particular product represents multiple design decisions each of which by itself might not be particularly problematic, but combined makes it “an accident waiting to happen.” Petroleum distillates are themselves potentially toxic. They do have an odor which is not attractive and are colorless. Adding citronella to it, adds a color which may be attractive to children, additionally it tends to impart an odor which is citrus-like and enhances its attractiveness to children. The container it is packaged in happens to be nearly exactly the same as used for fruit juices such as apple juice. The container is transparent and thus the juice-like liquid is readily visible, making the container appear to actually contain a fruit juice and making it more attractive. The container involved is designed to provide refill fuel for smaller torches that are often used for backyard parties often attended by children. The refilling often occurs at the scene of the party and then the refill container is often left in plain view. These parties often involve alcoholic beverages and “letting down the guard,” as to the supervision of children. The containers do have child-resistant caps on them. To be effective, they must be reapplied properly. The user often gets fuel on his/her hands and this makes manipulating the cap properly so that it is reapplied in such a way as to represent resistance to opening by a child. There is a requirement for proper warning labeling to be included. The problem with this is that an estimated 30% of the population is functionally illiterate and children, at the greatest risk, cannot read.
I would suggest changing the general package. Other similar products used for igniting charcoal are packaged in opaque containers. I believe that this would be a valuable start towards making the product safer. Further changing the color into one less attractive and less likely to be confused with juice would be useful. The labeling should clearly relate the dangers to even those functionally illiterate. The “pourability” should be improved. Since many of our exposures occurred when the user transferred product into a paper cup to enable pouring into the torch itself and the exposure came from drinking the remainder in the cup, making the neck top of the container more of a spout would potentially prevent that activity. A last suggestion is to include a funnel for use in pouring the substance into the torches. An alternative would be to design a spout that would enable easy filling of the torches without representing such a danger to children. Although none of these are “foolproof,” they show both an attempt to protect the public as well as being useful in an educational effort to accomplish safe use of the substance.
The expert is a board-certified pediatrician and medical toxicologist who designed and established that state’s poison information system.