Recurring concern

Failure to reliably investigate metabolic causes of acute clinical presentations

First to latest report 9 Aug 2023 — 4 Mar 2026

Reports that mention this concern: 3
Times this concern has been raised: 5
Stated actions linked to this concern: 2

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

4 Mar2026
Essex
Concerns raised1
1. 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.
Linked response

Mid and South Essex NHS Foundation Trust
Stated actions 1
1. Mid and South Essex NHS Foundation Trust
  Disseminate learning about metabolic acidosis and associated safety actions through multidisciplinary forums, teaching, simulation and a staff safety bulletin.
AI-generated summary

Viviana-Ray Winnie Elsie Wendy Butnaru · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Viviana-Ray Winnie Elsie Wendy Butnaru attended the Children’s Emergency Department on 24 October 2024 and died at Basildon Hospital on 25 October 2024 after cardiac arrest. The stated cause of death was myocarditis caused by Parvovirus, contributed to by bronchiolitis and bronchopneumonia. Concerns included delayed reporting of chest X-rays showing cardiomegaly, incomplete exploration of metabolic acidosis, failures in escalation and review processes, and incomplete documentation and handovers.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to fully explore underlying causes of metabolic acidosis
Wider context from the report
“(4) Underlying causes for metabolic acidosis were not fully explored. Greater awareness of the difference between metabolic and respiratory acidosis is required. ”
Source location
Viviana-Ray Winnie Elsie Wendy Butnaru · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Disseminate learning about metabolic acidosis and associated safety actions through multidisciplinary forums, teaching, simulation and a staff safety bulletin.

Verbatim wording from the response
“Viviana-Ray’s case has been discussed at various trust forums, to share learning and the associated actions that have been taken. The case was presented at Basildon’s site Mortality and Morbidity (M&M) meeting in March 2026, which is attended by consultants, tier 1 and 2 doctors and clinical nurse facilitators. Her case has also been discussed at the cross-site Grand Round in January 2026, during this meeting the case was discussed with learnings and differential for metabolic acidosis including cardiac and attended by consultants, tier 1 and 2 doctors and Associate Directors of Nursing. A safety bulletin has also been circulated to all staff in February 2026.”

Source location
Response from Mid and South Essex NHS Foundation Trust
Page 2 · response
Published 9 March 2026
Open published response
11 Feb2026
Birmingham and Solihull
Concerns raised3
1. Failure of RCEM investigation guidance to identify when metabolic screens and ammonia levels are clinically indicated
2. Omission of urea cycle and metabolic disorders from RCEM behavioural disturbance risk factors
3. 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.
Linked responses

National Institute for Health and Care Excellence
Royal College of Midwives
Royal College of Physicians
Respondent positions 5
1. National Institute for Health and Care Excellence
  Development of guidance on this area is best dealt with by specialist societies such as RCEM or BIMDG.
  Redirects responsibility
1. National Institute for Health and Care Excellence
  No additional recommendations are considered necessary because the existing RCEM guideline already addresses the relevant concerns.
  No action considered necessary
2. Royal College of Midwives
  Matters in points 3–11 are outside the respondent’s role, so it will not comment further on them.
  Outside remit
3. Royal College of Physicians
  Routine ammonia testing is not warranted in all confused patients because hyperammonaemia is a diagnosis of exclusion and sepsis requires priority assessment.
  Disputes the concern
4. Royal College of Midwives
  Without specific ammonia-testing recommendations, midwives follow national guidance and local policies and do not routinely initiate testing without medical discussion.
  Existing arrangements considered sufficient
AI-generated summary

Chloe Angela Ulett · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Chloe Angela Ulett died at Birmingham Heartlands Hospital on 28 September 2024 from a previously undiagnosed urea cycle disorder that had been unmasked by giving birth. She developed confusion and excessive drowsiness after childbirth, was initially diagnosed with iron deficiency and discharged, and ammonia testing was delayed until several days later. The principal concerns were that early ammonia testing was not routine, relevant guidance was unclear and not embedded in adult medicine, and there remained a national risk of delayed diagnosis.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of RCEM investigation guidance to identify when metabolic screens and ammonia levels are clinically indicated
Wider context from the report
“4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels. 5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology). 6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department. 7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version. 8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance. ”
Source location
Chloe Angela Ulett · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Omission of urea cycle and metabolic disorders from RCEM behavioural disturbance risk factors
Wider context from the report
“4. The Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in Adult Emergency Departments’ (Oct 2023) was the most appropriate guideline at the time, it advises doing tests as clinically indicated including appropriate metabolic screen to include blood tests to check ammonia levels. 5. The RCEM guidance was not, however, considered by any of the practitioners in this case (the deceased was treated in the emergency department, by the acute medical team and then in intensive care with several other specialities consulting before ammonia testing was recommended by neurology). 6. The evidence was that this RCEM guidance is not yet embedded in adult medicine in the emergency department. 7. Further, evidence was given that the content and phrasing of the RCEM guidance was not helpful in the context of a case of acute behavioural disorder resulting from a urea cycle disorder because urea cycle disorders or metabolic disorders (‘ABD’) are not contained in the table of potential factors leading to ABD presentation in section 1, and in section 4 the recommended investigations do not assist in identifying when metabolic screens, and specifically ammonia levels, are clinically indicated. Nor is it clear why ammonia levels are placed in brackets. Additionally, there is no guidance as to the appropriate referral pathway to be followed when ammonia levels are raised. The RCEM guidance was updated in May 2025 but these matters have not changed from the 2023 version. 8. It was acknowledged that the presentation of adults with undiagnosed Urea Cycle Disorders is very rare and ammonia levels will not normally be clinically indicated for patients with ABD. However, it is the rarity of these presentations and the likely inexperience of those outside inherited metabolic diseases teams that gives rise to the need for clear guidance. ”
Source location
Chloe Angela Ulett · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of best-practice guidance recommending ammonia testing for undifferentiated acutely confused patients
Wider context from the report
“2. There are no identified NICE or BMJ best practice guidelines which currently recommend testing of ammonia levels for undifferentiated acutely presenting confused patients. 3. Nationally, early measurement of ammonia levels in adults presenting to the emergency department and other units for investigation and management of behavioural change and confusion are not routine practice. ”
Source location
Chloe Angela Ulett · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Development of guidance on this area is best dealt with by specialist societies such as RCEM or BIMDG.

Verbatim wording from the response
“We believe that this is an area best dealt with by specialist societies, such as the RCEM or the British Inherited Metabolic Diseases Group (BIMDG). We note that you have already written to RCEM regarding their guidance and indicated that during the course of your inquest, evidence indicated that this guidance is not embedded in adult medicine at University Hospitals of Birmingham NHS Foundation Trust. NICE does not have anything to add to the recommendations provided by the RCEM guideline.”

Source location
2026-0086 - Response from NICE
Page 1 · response
Published 13 February 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
No additional recommendations are considered necessary because the existing RCEM guideline already addresses the relevant concerns.

Verbatim wording from the response
“We believe that this is an area best dealt with by specialist societies, such as the RCEM or the British Inherited Metabolic Diseases Group (BIMDG). We note that you have already written to RCEM regarding their guidance and indicated that during the course of your inquest, evidence indicated that this guidance is not embedded in adult medicine at University Hospitals of Birmingham NHS Foundation Trust. NICE does not have anything to add to the recommendations provided by the RCEM guideline.”

Source location
2026-0086 - Response from NICE
Page 1 · response
Published 13 February 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Matters in points 3–11 are outside the respondent’s role, so it will not comment further on them.

Verbatim wording from the response
“Points 3-11 do not relate to the role of the RCM and therefore we feel unable to comment further.”

Source location
2026-0086 - Response from Royal College of Midwives
Page 2 · response
Published 13 February 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Routine ammonia testing is not warranted in all confused patients because hyperammonaemia is a diagnosis of exclusion and sepsis requires priority assessment.

Verbatim wording from the response
“Hyperammonaemia is rare but the presentation of those with confusion due to any cause is high in the acute setting. 10-20% of all admissions present with confusion due to a wide variety of issues (National Institute for Health and Care Excellence: Delirium, prevention, diagnosis and management (CG103). London: NICE; 2010 (updated 2019)). Hyperammonaemia remains a diagnosis of exclusion and as such, ammonia levels are not usually in the first bloods sent for a patient, as the primary aim in someone presenting with confusion is to ensure they do not have sepsis. As highlighted by this challenging case, hyperammonaemia remains a diagnosis that should be carefully considered when the cause of acute confusion is unclear.”

Source location
2026-0086- Response from Royal College of Physicians
Page 2 · response
Published 13 February 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Without specific ammonia-testing recommendations, midwives follow national guidance and local policies and do not routinely initiate testing without medical discussion.

Verbatim wording from the response
“2. There are no identified NICE or BMJ best practice guidelines which currently recommend testing of ammonia levels for undifferentiated acutely presenting confused patients.”

Source location
2026-0086 - Response from Royal College of Midwives
Page 2 · response
Published 13 February 2026
Open published response
9 Aug2023
Milton Keynes
Concerns raised1
1. 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.
Linked response

NHS England
Stated actions 1
1. NHS England
  Issue a Patient Safety Bulletin highlighting prompt ammonia measurement and action when hyperammonaemia is identified.
Respondent positions 2
1. NHS England
  NHS England is not the lead organisation for developing guidance on ammonia testing in emergency departments.
  Outside remit
1. NHS England
  Concerns about ammonia-testing guidance should be referred to the Royal Colleges.
  Redirects responsibility
AI-generated summary

Rohan GODHANIA · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Rohan GODHANIA became unwell after consuming a high-protein drink on 15 August 2020, was admitted to hospital, and died on 18 August 2020 from Ornithine Transcarbamylase Deficiency. The report identifies concerns about inconsistent NHS classification of teenagers aged 16–18 and a lack of emergency-department guidance on ammonia testing for patients presenting in extremis with an unknown cause.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidance for testing ammonia levels in patients presenting in extremis with an unknown cause
Wider context from the report
“2. Guidance for Testing for Ammonia in Emergency Departments The other concerning issue that requires immediate attention is the lack of guidance for testing ammonia levels in patients who present in extremis with an unknown cause. Timely and accurate diagnosis is essential in such cases to ensure appropriate treatment and prevent unnecessary deaths. The guideline should include clear protocols for conducting ammonia tests, interpreting the results and making informed clinical decisions based on the findings. The guidance should be disseminated to all emergency departments and healthcare facilities. ”
Source location
Rohan GODHANIA · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Issue a Patient Safety Bulletin highlighting prompt ammonia measurement and action when hyperammonaemia is identified.

Verbatim wording from the response
“NHS England’s National Patient Safety Team have also undertaken work with the Royal College of Pathologists (RCPath) on the specific issue of hyperammonaemia and ammonia testing. As a result of this a Patient Safety Bulletin was issued. This highlighted the need for ‘prompt measurement of ammonia and action in the event of hyperammonaemia’.”

Source location
Response from NHS England
Page 2 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England is not the lead organisation for developing guidance on ammonia testing in emergency departments.

Verbatim wording from the response
“NHS England would not be the lead organisation for the relevant clinical guidance, and you may wish to refer your concerns to the Royal Colleges. NHS England has, however, engaged with the Royal College of Emergency Medicine (RCEM) on this case, and they have advised that they will be making an amendment to their existing Acute Behavioural Disturbance guidelines to specifically mention ammonia levels, should a clinician be considering the need for a metabolic screen.”

Source location
Response from NHS England
Page 2 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Concerns about ammonia-testing guidance should be referred to the Royal Colleges.

Verbatim wording from the response
“NHS England would not be the lead organisation for the relevant clinical guidance, and you may wish to refer your concerns to the Royal Colleges. NHS England has, however, engaged with the Royal College of Emergency Medicine (RCEM) on this case, and they have advised that they will be making an amendment to their existing Acute Behavioural Disturbance guidelines to specifically mention ammonia levels, should a clinician be considering the need for a metabolic screen.”

Source location
Response from NHS England
Page 2 · response
Published 6 September 2023
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure to fully explore underlying causes of metabolic acidosis

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

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

Linked responses

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised1

Lack of guidance for testing ammonia levels in patients presenting in extremis with an unknown cause

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Stated actions 1

Respondent positions 5

Stated actions 1

Respondent positions 2