Rohan GODHANIA · Prevention of Future Deaths report

On 02 November 2021 I commenced an investigation into the death of Rohan GODHANIA aged 16. The investigation concluded at the end of the inquest on 21 July 2023. The narrative conclusion of the inquest was:

The deceased was admitted to West Middlesex Hospital on 16th August 2020. His hyperammonaemia and OTC deficiency was not diagnosed. The failure to carry out a test for ammonia that would have revealed the hyperammonaemia resulted in a lost opportunity to render further medical treatment that may, on the balance of probabilities, have prevented his death. He died on 18th August 2020.

The deceased consumed a high protein drink on 15th August 2020 and became unwell. He was admitted to West Middlesex Hospital. Advice was taken from the neurologists at Charing Cross Hospital who advised that he should be tested for ammonia. The test was not carried carried out. His condition deteriorated and he died from Ornithine Transcarbamylase Deficiency (OTC) on the 18th August 2020.

During the cause of the evidence I had two concerns regarding the treatment of the deceased that, as part of my duty as a coroner, I am bringing to your attention

1. Age classification of Teenagers 16-18 within the NHS

There seems to be a lack of clarity and consistent guidance across the NHS regarding the appropriate classification of teenagers aged 16-18. The question of whether they should be treated as paediatric patients or adults is leading to confusion and potential disparities in the care provided. I consider that this should be urgently reviewed by NHS England and if necessary the guidance on age classification updated ensuring that all healthcare providers adhere to a unified approach emphasising the importance of consistent and appropriate care for this age group.

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.