Chloe Ulett

Miss Emma Brown 
Area Coroner for Birmingham and Solihull 
VIA EMAIL 

18 March 2026 

Dear Miss Brown 

Re: Regulation 28 Report to Prevent Future Deaths – Ms Chloe Ulett 

Firstly, we wish to express our sincere condolences to the family of Chloe.   

As your report highlights, disorders of urea metabolism are rare and diagnostically challenging, 
however an early diagnosis is important. 

In order to raise awareness, we will highlight this case in our tri-annual Safety Bulletin. The Safety 
Bulletin is sent to all Fellows and Members of the Faculty of Intensive Care Medicine, and is a 
mechanism for promoting learning, with the aim of reducing risk. Through the Safety Bulletin, we will 
signpost open access resources for and will also highlight the utility of testing ammonia levels in 
encephalopathy of unknown cause.  

In addition, we will draw attention to this being the second Regulation 28 Report in recent years 
which has stressed the need to test ammonia levels in patients who present in extremis with an 
unknown cause. That Regulation 28 Report was issued by the Senior Coroner of Milton Keynes in 2023 
and concerned the death of Rohan Godhania. 

If you have any further questions, please don’t hesitate to contact the Faculty at 

Kind regards 

Dean, FICM

2nd Floor 
2 Redman Place 
London 
E20 1JQ 
United Kingdom 

18 March 2026 

Ms Emma Brown 

Area Coroner for Birmingham and Solihull. 

Sent via email: 

Our reference: 

Dear Ms Brown,    

Re: Regulation 28 Prevention of Future Deaths Report in respect of Chloe Angela Ulett 

I write in response to your regulation 28 report dated 11 February 2026 regarding the sad 
death of Chloe Angela Ulett. I would like to express my sincere condolences to Miss Ulett’s 
family.   

We have reflected on the circumstances surrounding Miss Ulett’s death and the concerns 
raised in your report. We note that the matters of concern in your report relate mainly to the 
Royal College of Emergency Medicine (RCEM) guideline ‘Acute Behavioural Disturbance in 
Emergency Departments’, and that the report has been copied to NICE for information. 

Senior clinical advisors within the patient safety team here at NICE have reviewed the report 
and outlined the following, which we hope is useful.  

N-acetylglutamate synthase deficiency is a rare disorder (estimated frequency 1 in 2 million 
worldwide, with the majority presenting in infancy). As described in your report, NICE does 
not have specific guidance on this condition or on the detection of hyperammonaemia.  

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. 

Thank you again for sharing this report with NICE. I hope our response has helped outline 
our role and the guidance that exists in this topic area. I would like to reiterate my sincere 
condolences to Miss Ulett’s family.   

Best regards,  

 
 
 
 
 
 
 
 Chief Executive 

                                                                                                                                 Page | 2

Private & Confidential 

Emma Brown, Area Coroner for the jurisdiction of Birmingham and Solihull  
Sent by email to: 

4 March 2026 

Dear Ms Brown,  

Royal College of Midwives (RCM) response to Regulation 28: Report to Prevent 
Future Deaths Ref no: 46425464 

Thank  you  for  your  Regulation  28  Report  to  Prevent  Future  deaths  following  the 
inquest into the death of Miss Chloe Ulett.  

The Royal College of Midwives (RCM) would like to begin by expressing our sincere 
condolences to the family and all those affected by the death of Chloe Ulett.  

The RCM is a professional association and trade union and does not hold statutory or 
operational  responsibility  for the delivery  of maternity  services.  However,  we play  a 
key  role  in  representing  the  professional  voice  of  midwives,  influencing  policy, 
representing midwives and maternity support workers both individually and collectively 
in  the  workplace  and  working  collaboratively  with  practice  partners  to  advocate  for 
safe,  effective  and  high-quality  maternity  care. The  response  to  this  report  is  in  the 
context of our responsibilities as a stakeholder within maternity services.  

We have carefully considered the matters of concern in your report. While the RCM 
does  not  have  authority  to  implement  changes  at  service-level,  we  have  identified 
actions under each point that are within our remit and/or sphere of influence: 

1.  The window of opportunity to consider and make a diagnosis of a metabolic 
disorder and institute effective treatment is very short, 24 to 48 hours from 
the  commencement  of  symptoms,  and  relies  on  early  measurement  of 
ammonia in an adult presenting with behavioural change and confusion. 

Midwives  have  a  key  role  in  recognising  acute  changes  in  behaviour,  cognition  or 
consciousness in women throughout pregnancy, postnatally or in those with complex 
medical histories. Sudden confusion, agitation, reduced responsiveness, or unusual 

 
 
  
 
 behaviour  should  always  be  treated  a  clinical  red  flag.    Any  unexplained  acute 
confusion  should  be  escalated  urgently  to  medical  staff,  using  local  escalation 
pathways and early warning systems.  

Learning  from  this  case  highlights  the  importance  of  maintaining  a  high  index  of 
suspicion  when  women  present  with  unexplained  neurological  or  behavioural 
symptoms. Midwives are reminded to treat such presentations as clinical red flags and 
to escalate concerns promptly using established local pathways. 

 Actions should include reinforcing education on the recognition of acute changes in 
mental status and their potential clinical significance. This should be delivered through 
mandatory  training  and  regular  clinical  updates  and  strengthened  through  practice 
education across NHS England. Local and regional protocols should also be reviewed 
and updated to ensure consideration of ammonia testing when altered behaviour or 
confusion is identified, which is within the remit of NHS England. 

2. There are no identified NICE or BMJ best practice guidelines which currently 
recommend  testing  of  ammonia  levels  for  undifferentiated  acutely  presenting 
confused patients.  

Midwives are expected to practise in line with national guidance and local policies. In 
the absence of specific recommendations for ammonia testing, midwives would not 
routinely initiate such investigations without discussing clinical concerns with medical 
staff.  NICE are responsible for development of national guidance to address maternal 
assessment  or  to  link  to  associated  guidance  for  adult  medical  assessment  and 
treatment.  The  RCM  would  contribute  professional  expertise  through  consultation 
process as appropriate. 

Points 3-11 do not relate to the role of the RCM and therefore we feel unable to 
comment further. 

Thank  you  again  for  raising  these  matters  with  the  RCM.  We  trust  this  response 
addresses  the  matters  raised  in  your  report.  Please  let  us  know  if  any  further 
information or clarification is required. 

Yours sincerely 

CEO, General Secretary & Chief Midwife 
The Royal College of Midwives

Emma Brown 
His Majesty’s Senior Coroner for the Coroner area of Birmingham and Solihull 
The Birmingham and Solihull Coroner’s Court,  
Steelhouse Lane,  
Birmingham,  
B4 6BJ 

15 April 2026 

Dear Ms Brown  

Re: Chloe Angela Ulett 

Thank you for your Regulation 28 Report to Prevent Future Deaths following the inquest into the 
death of Chloe, dated 12 February 2026, and for granting an extension to enable us to provide a 
thorough response. 

The loss of a loved one is a devastating tragedy for the family and healthcare professionals involved. 
We would like to begin by extending our deepest and heartfelt condolences to Chloe’s family for 
their profound loss. 

This response has been developed following input from members of the Royal College of 
Obstetricians and Gynaecologists (RCOG) Patient Safety Committee as well as Officers of the College.  

We acknowledge from the matters of concern that there can be a lack of awareness amongst all 
medical specialties that behavioural disturbance and altered consciousness can be symptoms of a 
previously undiagnosed metabolic disorder.  This is of importance in obstetrics because such 
conditions can become unmasked by giving birth and there is a short window for diagnosis and 
treatment. 

The RCOG encourages multi-professional, cross-specialty collaboration in the care of all women.  
This is of particular importance for pregnant women (or those in the postpartum period) who have 
pre-existing medical conditions, symptoms which are not typically suggestive of common obstetric 
conditions, and symptoms which are worsening or not improving despite standard treatment.  This 
expectation is outlined in the RCOG Maternity Services Standard Framework 2025: 

5.2. Commissioners and service providers should utilise multidisciplinary working to ensure 
that women and birthing people with complex medical needs have access to the expertise, 
specialised care and support appropriate to their needs. (Royal College of Obstetricians and 
Gynaecologists, 2025, p. 55) 

1 

 
 
 
 
      
 
 
 
 
 
 
  
 
 
 
 
 
 This recommendation is embedded in RCOG clinical guidance and good practice papers, and in our 
curriculum and our courses.   

The RCOG’s Maternity Services Standards Framework also outlines the role of maternal medicine 
networks: 

5.2.2 Oversight of the care of women with suspected or confirmed medical disorders, 
particularly when complex or severe, should be provided by a multidisciplinary team as part 
of a maternal medicine network. (Royal College of Obstetricians and Gynaecologists, 2025, p. 
55) 

Maternal medicine networks are multidisciplinary teams of experts who are experienced in 
managing a wide range of pre-existing and newly arising medical conditions during pregnancy and in 
the postpartum period.  These teams can be contacted and consulted with for any woman during 
the antenatal or postnatal period who is acutely unwell, particularly where that woman has unusual 
or concerning symptoms. 

In response to the concern that there may be a lack of awareness of urea cycle disorders amongst 
obstetricians, the RCOG has commissioned an article covering ‘Metabolic Conditions in the 
Peripartum Period’, to be published in The Obstetrician and Gynaecologist Journal (TOG).  This 
journal is widely read by members, fellows and trainees in obstetrics and gynaecology, and as such, 
is an effective way of disseminating this clinical information.   

Articles published in TOG are often used as a basis for questions in the College’s Membership 
examination (MRCOG) and therefore are essential reading for all doctors embarking upon 
membership of the RCOG. 

Once again, we offer our deepest condolences to Chloe’s family. Thank you for bringing this to our 
attention. I hope this is a helpful response to this matter.   

Yours sincerely, 

References 
Royal College of Obstetricians and Gynaecologists. (2025). Maternity Service Standards Framework. 
Retrieved from https://www.rcog.org.uk/media/0i0afzvd/maternity-service-standards-framework-
december-2025.pdf 

2

Care Quality Improvement Directorate 
Royal College of Physicians 
The Spine  
2 Paddington Village 
Liverpool 
L7 3FA 

www.rcp.ac.uk 

9 April 2026 

Subject: Royal College of Physicians response to Regulation 28 report to prevent future deaths  

Dear Emma Brown,  

The Royal College of Physicians (RCP) notes the matters of concern contained within the Regulation 
28 Prevention of Future Deaths report related to the death of Miss Chloe Angela Ulett. We send our 
sincere condolences to the family of Miss Chloe Angela Ulett. 

To ensure an informed and comprehensive response to this case, we have consulted the RCP’s 
Patient safety committee, which comprises a number of our national stakeholders including NHSE, as 
well as acute medicine colleagues, including the Society of Acute Medicine and those with a special 
interest in metabolic disorders. 

This regulation 28 report raises the concerns around the diagnosis of hyperammonaemia. 
Hyperammonaemia is characterised by the rise of ammonia within the blood stream which can result 
in patients becoming confused, drowsy and have headaches.  

Severe hyperammonaemia is well recognised as a metabolic emergency. Its main causes can be split 
into the following subsections: 

a)  Overproduction of anaemia - caused by increased protein load, increased catabolism and 

urinary issues (for example, urease-producing infections) 

b)  Reduced elimination due to liver failure, drugs and toxins and metabolic disorders. 

The majority of patients who present with high ammonia levels in the blood have acute or chronic 
liver failure, but other causes of raised ammonia need to be considered as this is a diagnosis which 
has fatal consequences, as this case sadly demonstrates. Many of the inherited causes of 
hyperammonaemia are recognised in infancy. Indeed, urea cycle disorders are rare, affecting 
1:35,000-50,000 infants. The point prevalence in adults is significantly lower. 

Whilst guidelines in the Investigation of Hyperammonaemia in children and adults are available from 
NHS Scotland, there are currently no formal guidelines on investigation of hyperammonaemia in 
adults in England, although advice is available from the British Inherited Metabolic Disease Group. 
There is reference to the investigation of high ammonia in confused patients within the Royal College 
of Emergency Medicine (RCEM) best practice guideline ‘Acute Behavioural Disturbance in the 
Emergency Departments’ (October 2023) as stated in this  Regulation 28 report. This guideline 
advises doing ‘other tests as clinically indicated e.g. … appropriate metabolic screen (including 
ammonia level)’ in those with acute behavioural disturbance. The Royal College of Paediatrics and 

 
 
 
 
 
 
 
 
  
 
 
 
 
 Child Health (RCPCH) has also produced a clinical guideline document for the management of 
children and young people with an acute decreased in conscious level. The RCP is aware that the NHS 
England National Patient Safety Team have undertaken work with the Royal College of Pathologists 
(RCPath) on the specific issue of hyperammonaemia and ammonia testing and that as a result, a 
national Patient Safety Bulletin was issued. The RCP supports the highlighted need  for ‘prompt 
measurement of ammonia and action in the event of hyperammonaemia’. The RCP notes a gap in 
best practices guidelines as neither NICE nor the BMJ currently recommend the testing of ammonia 
levels for undifferentiated acutely presenting confused patients, as stated within the Regulation 28. 

While RCEM guidance exists, this case illustrates opportunities for enhanced awareness regarding 
the possibility of hyperammonaemia in patients presenting with acute behavioral changes and 
seeking urgent advice if the cause of acute deterioration is unclear particularly in someone with no 
other underlying health disorder. Over the past decade, additional cases associated with metabolic 
disease have been noted at inquests, which highlights the importance of continuing to increase 
recognition of this disorder which is treatable. 

The RCP recognises that physicians are working in very busy environments, but training should 
emphasise the importance of early intervention and advise, particularly for acute deterioration 
without cause in someone with no other health issues. Those physicians working in acute medicine 
as well as those in other medical specialities should be aware of these potential rare diagnoses, such 
as hyperammonaemia presenting acutely in adults. The RCP also advocates for urgent specialist 
reviews where diagnostic uncertainty exists, for example, assessment by a neurologist to help 
identify the diagnosis, ensuring management is not delayed.  The RCP acknowledges that the 
available guidance is not well embedded and the triggers for the condition described are not well 
known by the majority of clinicians. At the RCP, the concerns of hyperammonaemia have been 
discussed at the Patient Safety Committee and the RCP has committed to raising the profile by 
sharing this issue with their members via the RCP website within the coming months. 

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. Awareness of this condition varies among clinicians, and our 
review of this regulation 28 report underscores the value of developing clearer guidance on the 
investigation and management of hyperammonaemia, particularly in Trusts without access to 
metabolic medicine specialists. 

We suggest that any guidance produced would need to be created with the RCP, RCEM and the 
Society of Acute Medicine to ensure practical implementation. Guidance would need to be realistic 
and deliverable, especially given metabolic diseases are rare. There is also a risk that a significant 
number of patients would be over-investigated (given numbers who present with confusion vs those 
with metabolic disorders which result in hyperammonaemia) and thus may cause harm to patients. 
Any guidance would need to balance this risk with the risk of not identifying a potentially 
reversible/treatable condition which without intervention, has devastating consequences. At the RCP, 
we would be happy to contribute to the development of such guidance this should be shared 
nationally to enable systems learning. At the RCP, we could support by facilitating information and 
guidance sharing with our physician members and fellows as well as other stakeholders and we urge 
UHB to share this information with the RCP for this purpose. Furthermore, it would be valuable for 
the stakeholders and specialties regularly involved in these scenarios to collate available evidence 
including success stories and examples of efficient management of these rare events. In preventing 
future deaths, as a profession we have a duty to consider how such rare disorders (many of which 

 
 
 
 
 have serious, even fatal, consequences) are recognised and how information is disseminated to 
physicians who will see such a case perhaps only once in their career, if at all. 

Furthermore, we acknowledge that the window of opportunity to make such a diagnosis is relatively 
small, 24 to 48 hours from commencement of symptoms and therefore it should be a condition 
which should be considered in those presenting with symptoms. There are practical considerations 
and one of the recognised barriers is believed to be the measurement of ammonia. Indeed, the false 
positive rates of this test are high. This is because ammonia rises rapidly in the blood unless specific 
precautions are taken, and in some centres, the physical transporting of the blood to the laboratory 
precludes any chance of accurate levels being measured. The sample also needs to be kept on ice, 
which is no longer readily available in NHS Trusts, therefore causing challenges in completion of this 
investigation. NHS Trusts should have clear pathways for medical and nursing staff to follow in cases 
where a test for ammonia is required and appropriate.  

Our review of the case underscores the value of considering urea cycle disorders in pregnant or 
postpartum individuals experiencing unexplained confusion or critical illness and highlights the 
importance of awareness of the benefit of involving the regional maternal network in such instances. 
All regions have access to these networks, and increasing awareness of this resource is vital to 
optimal care of pregnant and postpartum women. 

The benefit of referring a patient where there is concern is that the network would have convened a 
multidisciplinary team including obstetrics, obstetric physicians and select specialist physicians and 
anaesthetists at short notice, who would then have been able to advise on investigation, diagnosis 
and management. The awareness of the networks and how to access them needs to be reinforced to 
all those who are involved in the assessment of pregnant and postpartum women. In any future 
communication to our members and fellows we will aim to emphasise this point so people are aware 
of the networks that would be useful, particularly in supporting postpartum or pregnant patients. 

Once again, our sincere condolences to Miss Ulett’s family at this difficult time. 

Yours sincerely, 

Clinical Director for Patient Safety and Clinical Standards