A coroner has warned more people could die from protein shakes after a teenager suffered 'irreversible brain damage' and passed away three days later when doctors failed to test for ammonia.
Rohan Godhania became unwell having consumed the drink and died after advice from neurologists suggesting he be tested for ammonia were ignored.
The 16-year-old's condition deteriorated and he tragically died two days later in August 2020, having suffered from undiagnosed Ornithine Transcarbamylase Deficiency (OTC) - a urea cycle disorder which prevents the breakdown of ammonia.
Now, senior coroner for Milton Keynes Tom Osborne written to NHS England and the Food Standards Agency urging the use of 'prominent' warnings on labels of protein products, as evidence suggests there is 'a risk that future deaths will occur'.
He has also urged for the classification of 16 to 18-year-olds to be reviewed, after a paediatric neurology professor raised concerns the teenager had not received 'quality of care' as a result of confusion over whether Rohan should receive paediatric or adult care.
Ammonia is a waste product made by the body in the digestion of protein, however OTC allows ammonia to accumulate, rising to toxic levels where it affects the central nervous system.
In a Prevention of Future Deaths report, senior coroner Tom Osborne revealed 'matters giving rise to concern' that had arisen throughout Rohan's inquest about the treatment of teenagers within the NHS and guidance for testing for ammonia.
One requiring 'immediate attention' was regarding the 'lack of guidance' for testing for ammonia levels in patients who 'present in extremis with an unknown cause' in emergency departments.
Mr Osborne wrote: '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.'
In a Prevention of Future Deaths report, senior coroner Tom Osborne revealed 'matters giving rise to concern' that had arisen throughout Rohan's inquest about the treatment of teenagers within the NHS and guidance for testing for ammonia.
One requiring 'immediate attention' was regarding the 'lack of guidance' for testing for ammonia levels in patients who 'present in extremis with an unknown cause' in emergency departments.
Mr Osborne wrote: '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.'