Coroner supports parents' concerns following death of Rohan Godhania
With thanks to Pritesh Rathod, Counsel at 1 Crown Office Row, instructed to represent Rohan's family at inquest.
'At the Inquest, held before Mr Tom Osborne, HM Senior Coroner for Milton Keynes, the family questioned whether Rohan’s condition could have been diagnosed and treated sooner.
The Coroner found that the neurologists at Charing Cross Hospital advised carrying out an ammonia test but that this advice was not heeded and the test was never performed. The Coroner found that there was a lost opportunity to render further medical treatment that may, on the balance of probabilities, have prevented Rohan’s death.
The Coroner decided to issue a prevention of future death (regulation 28) report to the Food Standards Agency to consider whether warning labels should be placed on protein shakes about the risk of having a violent reaction.
The Coroner was also concerned about the appropriate care of 16-18 year olds and remarked during the inquest that they were at risk of “falling between two stools”. He issued a further regulation 28 report to NHS England asking them to review the guidance relating to this cohort of patients.
The inquest proceedings also considered the propriety of authorising organ donation before the cause of death is known. As it happens, the Chief Coroner’s Guidance on Organ and Tissue Donation (No. 26) was revised extensively a week prior to the resumption of the Inquest and now contains substantial guidance to Coroners about the need to consider whether the organ being considered for donation contributed to death.'
Sarah supported Rohan's parents at inquest.