First reported 9 Aug 2023•Latest report 4 Mar 2026
Definition
What this concern includes
Includes failures to recognise, investigate or escalate possible metabolic causes of acute or unexplained presentations, including incomplete exploration of metabolic acidosis causes and unclear guidance on when metabolic screening or ammonia testing is indicated.
Not included
Excludes general diagnostic delays or incomplete clinical investigations where a metabolic cause is not materially involved.
Excludes treatment failures after an appropriate metabolic cause has been investigated and identified.
Excludes condition-specific metabolic pathways when the assertion is confined to a more specific established concern.
Excludes generic training, communication or documentation deficiencies unless they directly impair investigation of metabolic causes.
Reports
3
Distinct published reports
Individual concerns
5
A report can raise multiple concerns
Date range
2023–2026
First to latest report issue date
Stated actions
2
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Faculty of Intensive Care Medicine1
Food Standards Agency1
Mid and South Essex NHS Foundation Trust1
NHS England1
Royal College of Emergency Medicine1
Royal College of Midwives1
Royal College of Obstetricians and Gynaecologists1
Royal College of Paediatrics and Child Health1
Royal College of Physicians1
Executive non-departmental public body1
Food safety regulator1
Health professional body1
NHS trust1
Professional body1
Trade union and professional body1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Essex
Concerns raised1
Failure to fully explore underlying causes of metabolic acidosis
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Disseminate learning about metabolic acidosis and associated safety actions through multidisciplinary forums, teaching, simulation and a staff safety bulletin.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2026.
Birmingham and Solihull
Concerns raised3
Failure of RCEM investigation guidance to identify when metabolic screens and ammonia levels are clinically indicated
Omission of urea cycle and metabolic disorders from RCEM behavioural disturbance risk factors
Lack of best-practice guidance recommending ammonia testing for undifferentiated acutely confused patients
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Development of guidance on this area is best dealt with by specialist societies such as RCEM or BIMDG.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
No additional recommendations are considered necessary because the existing RCEM guideline already addresses the relevant concerns.
Stated by National Institute for Health and Care ExcellenceNo action considered necessaryThe respondent said that no further action was needed.
Position
Matters in points 3–11 are outside the respondent’s role, so it will not comment further on them.
Stated by Royal College of MidwivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
Routine ammonia testing is not warranted in all confused patients because hyperammonaemia is a diagnosis of exclusion and sepsis requires priority assessment.
Stated by Royal College of PhysiciansDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Without specific ammonia-testing recommendations, midwives follow national guidance and local policies and do not routinely initiate testing without medical discussion.
Stated by Royal College of MidwivesExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Milton Keynes
Concerns raised1
Lack of guidance for testing ammonia levels in patients presenting in extremis with an unknown cause
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Issue a Patient Safety Bulletin highlighting prompt ammonia measurement and action when hyperammonaemia is identified.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NHS England is not the lead organisation for developing guidance on ammonia testing in emergency departments.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Concerns about ammonia-testing guidance should be referred to the Royal Colleges.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures to recognise, investigate or escalate possible metabolic causes of acute or unexplained presentations, including incomplete exploration of metabolic acidosis causes and unclear guidance on when metabolic screening or ammonia testing is indicated.
