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A rare case of hyperammonaemic encephalopathy. A 75-year-old female patient presented to the accident and emergency department following a collapse. She was treated for a saddle pulmonary embolism and underlying urinary tract infection. However, 48 hours later she was found to have reduced consciousness with no apparent cause (Glasgow Coma Scale of 8 out of 15). Subsequent blood results revealed a highammonia level. After reflection into her medical history, it was found that she had bladder exstrophy, which was managed with urinary diversion surgery as an infant, and her presentation was a rare complication of this operation.