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Coroner says there were ‘lost opportunities’ in baby’s care

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lost opportunitiesTHERE were “lost opportunities” in the care of a premature baby who died after being removed from a ventilator, a coroner has said.

Rohan Rhodes, of Narberth, was born 15 weeks early at Singleton Hospital in Swansea on August 27, 2012, weighing 814g (1lb 12oz). He was placed on a ventilator at the hospital’s neonatal intensive care unit, where he was described as “doing well” for four weeks after his birth. Flax Bourton Coroner’s Court heard the medical team’s plan was to keep Rohan on the ventilator ahead of his upcoming surgery.

But advanced neonatal nurse Amanda Dallorzo took the “autonomous” decision to remove the machine and put a breathing mask on Rohan instead. Within an hour, Rohan’s condition dramatically deteriorated and he developed NEC, a gastrointestinal disease, which required surgery.

Tragically, Rohan never became stable for the operation and he died, aged 36 days, in an incubator at the hospital with parents Alex and Bronwyn Rhodes close by.

Avon Coroner Maria Voisin recorded a narrative verdict following a three day inquest into Rohan’s death. She said three blood gas readings should have been taken to check Rohan’s condition but were not, resulting in “lost opportunities” to treat the baby.

“Rohan Rhodes was an extremely premature baby who was at risk of developing NEC,” Ms Voisin said.

“He developed this condition which caused his death on September 30.

“On September 29, there were three occasions when he should have had a blood gas test.

“It is not known what results would have been but these were lost opportunities which may have resulted in Rohan receiving earlier medical care.”

She told Rohan’s parents: “I am very sorry for your loss.”

Ms Voisin said the blood gas tests should have been taken directly after Ms Dallorzo removed Rohan from the ventilator, at 4pm on September 29. A second test should have been taken at 5pm, when it was noticed that a breathing mask placed on Rohan was leaking.

The final “lost opportunity” was after Rohan was put back on the ventilator, at 7.30pm that evening, Ms Voisin said. Rohan died at 6pm the following day.

Dr David Harding, lead clinician at St Michael’s Hospital, told the inquest the ward was short-staffed and at full capacity when Rohan was treated. At 4pm on September 29, Rohan was extubated by Ms Dallorzo – who did not consult Rohan’s parents or doctors on the ward – and nurse Suja Thomas.

“Rohan was extubated at 4pm and the ANNP (advanced neonatal nurse practitioner Ms Dallorzo) said it was her intention to check Rohan’s blood gas but she didn’t as she was too busy,” Ms Voisin said.

Rohan deteriorated within an hour.

Dr Vel Ramalingam, the registrar on the ward told how he found Rohan had been extubated and put on breathing mask treatment Continuous Positive Airway Pressure (CPAP).

Rohan’s heart was slowing and the mask was leaking, so Dr Ramalingam requested a blood gas from Ms Thomas and that she apply nasal prongs to Rohan.

“In evidence, Dr Ramalingam said he requested a blood gas to be carried out,” Ms Voisin said.

“This was not carried out.”

Ms Thomas removed the prongs and placed the mask back on Rohan within 30 minutes as he was crying.

At 6.30pm, Rohan became bradycardic as his parents changed his nappy, with his heart rate falling into the 20s at one point.

He was reintubated by 7.30pm.“The nurse practitioner said she intended to repeat the blood gas but was pulled away,” Ms Voisin said.

As Rohan was reintubated, his body temperature dropped to 33.6 degrees – around three lower than normal.

“It later became clear his humidifier has been left off,” Ms Voisin said.

His temperature did not recover until 11pm, the inquest previously heard.

Rohan’s blood gas had been taken at 1.47pm on Saturday 29 – two hours before he was removed from the ventilator. It was next checked at 12.13, almost 12 hours later. Results showed lactic acid and carbon dioxide was building, meaning his condition was weakening.

“By 2.30pm, Rohan was considered to be in circulatory collapse,” the coroner said.

“An abdominal x-ray at 5.12 showed a perforation and a consultant was called.

“The surgeon was called at 6am but sadly Rohan was never stable enough for surgery.”

Rohan went into cardiac collapse at 4pm that day and required resuscitation. An hour later, his mother, vet Mrs Rhodes, told doctors to stop resuscitation. She begged doctors to let him pass away in her arms, but they were unable to remove the lines from his body in time.

He died in his incubator at 6pm on September 30. Ms Voisin said the cause of Rohan’s death should be recorded as acute peritonitis and pneumonia, NEC and prematurity.

Rohan’s family are considering legal action following the inquest.

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Police appeal after man found dead near Kilgetty roundabout

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POLICE in Pembrokeshire are  investigating the sudden death of a man in Kilgetty, Pembrokeshire.

The man, aged in his 60s, is often seen on or near Kilgetty roundabout. Concerns for his welfare were raised this morning (Saturday, Nov 28) and sadly, a body was found near the Kilgetty roundabout a short while later.

Police said: “Anyone with information that could help piece together the circumstances surrounding his death, which is being treated as unexplained, is asked to contact police.

“Though formal identification has not yet taken place, the man’s next of kin has been informed. HM Coroner is also aware.

“Anyone with information that could help officers with their investigation is asked to report it to Dyfed-Powys Police, either online at: bit.ly/DPPContactOnline, by emailing 101@dyfed-powys.pnn.police.uk, or by calling 101. If you are deaf, hard of hearing, or speech impaired text the non-emergency number on 07811 311 908. Quote reference: DP-20201128-076.”

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Garage planning appeal dismissed

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A PLANNING inspector has upheld a Pembrokeshire County Council decision to refuse planning permission for a detached garage.

The Inspector dismissed the appeal by Mr Peter Baker against the Council’s decision to refuse the proposed development at Amroth Road, Ludchurch.

Planning Inspector J P Tudor agreed that the development would cause unacceptable harm on the character and appearance of the area.

The planned garage was to be placed in front of a detached bungalow.

Other properties nearby generally have garages situated to the side or rear or integrated into the main building.

The Inspector said: “Given its size and position, the garage would appear prominent in public views along the highway and be noticeable from neighbouring properties. It would compromise the existing sense of space and openness to the front of most dwellings.

“Therefore, the development would have an adverse effect on the character an appearance of the area.”

The appeal was dismissed.

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New guidelines for hospital visiting during Coronavirus outbreak

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NEW revised NHS Wales hospital visiting guidance during the coronavirus outbreak will be published on Monday 30 November 2020. This supersedes previously published guidance.

The revised guidance sets out the baseline for visiting in Wales during the pandemic, but allows health boards, trusts and hospices to have more flexibility to depart from the guidance.

This flexibility is due to the changing picture of coronavirus transmission across Wales, with significant variations in community transmission across different parts of the country and differences in the rate of nosocomial transmission.

The new guidelines allow health care providers to asses local factors and work with local infection prevention and control teams and Public Health Wales when agreeing visiting arrangements.

Healthcare providers may depart from the guidance in response to:

  • rising levels of covid-19 transmission in their localities, including levels which result in a national lockdown and/or evidence of nosocomial transmission in a particular setting; or
  • falling levels of transmission in their local area.

In addition to allowing for this flexibility the revised guidance has been amended for maternity services after listening to feedback from women and families and consulting with Heads of Midwifery and Sonography/Radiography Services. Visiting in maternity services will now be based on a risk assessment approach by health boards. This will take into consideration local environmental factors such as room sizes, ability to socially distance and infection prevention and control risks in enabling partners to safely accompany pregnant women and new mothers. This risk assessed approach should be taken in collaboration with relevant health professionals, local infection prevention and control teams and Public Health Wales. All women will be supported to have at least one partner with them during active labour, birth and for the period immediately after the birth, except in an extremely limited number of circumstances.

The updated guidelines also recognise that some people may require an essential support assistant for specific additional support eg a support worker or interpreter. Essential support assistants will not to be classed as visitors, in some circumstances, where people receive care and support from a family member or partner, they may nominate this person as their essential support assistant.

Minister for Health and Social Services Vaughan Gething, said: “We recognise that the restrictions on visiting has a huge impact on patients, their families and loves ones. We have announced further changes to the guidelines today to provide health boards, trusts and hospices with flexibility to depart from the guidelines in response to local levels of Covid-19 transmission. It is important to remember that the virus has not gone away and the health, safety and wellbeing of patients, communities and NHS staff remains an absolute priority for both the Welsh Government and health care providers. Tough choices will still need to be made but we hope the revised guidelines will allow more flexibility for health care providers. ”

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