Milton Keynes Coroner issues grim warning about protein shakes following death of teenage boy

The coroner forMilton Keyneshas issued a grim warning about the dangers of drinking popular high protein shakes.

He has issued aPrevention of Future Deaths reportfollowing the tragedy of 16-year-old Rohan Godhania, who became ill after consuming the drink made from a single scoop of powder and died three days later.

Rohan suffered irreversible brain damage due to an undiagnosed Ornithine Transcarbamylase Deficiency (OTC), a urea disorder that prevents the breakdown of ammonia.

Ammonia is a waste product the body produces when it digests protein. But OTC can cause it to reach toxic levels and affect the central nervous system.

In Rohan’s case, the OTC was not diagnosed, says coroner Tom Osborne.

“为氨,未能进行测试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,” his report states.

Rohan died on August 2020 at 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,” said Mr Osborne, who conducted the inquest two months ago.“In my opinion there is a risk that future deaths could occur unless action is taken.”The coroner’s first concern is the age classification within the NHS of teenagers aged between 16 and 18.

“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,” says the report.

"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.”

Secondly, the coroner is concerned about the guidance for testing of ammonia in emergency departments. There is a lack of guidance for testin levels in patients who present in extremis with an unknown cause, says Mr Osborne.

“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...”

The report adds: “In my opinion there is a risk that future deaths could occur unless action is taken..”

The coroner is asking health chiefs to consider whether high protein shakes should carry a warning,

“High protein supplements and drinks are easily accessible to the general public, yet their labels fail to adequately inform consumers about the potential dangers posed to individuals with urea cycle disorders, such as Ornithine Transcarbamylase (OTC) deficiency,” states the report.

“Consideration should be given as to whether the labels should prominently display a warning about the potential risks for individuals with an undiagnosed urea cycle disorder and include clear and concise information on symptoms of this and the importance of seeking immediate medical advice.”

The report has been sent to West Middlesex Hospital, Imperial College NHS Trust and also the Care Quality Commission. They must respond with 56 days.