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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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Angle Lifeboat tasked to disabled yacht 22miles from St Ann’s head

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Image Credit - RNLI Penny Harris

ANGLE LIFEBOAT and her crew saw out April when they were tasked on 30th of April to a yacht 22miles from St Ann’s head.

Angle Lifeboat and her crew saw out April when they were tasked on 30th of April to a yacht 22miles from St Ann’s head.

The lifeboat was launched at 10:43pm to a 26ft yacht that had reported smoke coming from their engine compartment. The casualty vessel was 22 miles south west of St Ann’s with two crew onboard.

The lifeboat arrived on scene at 11:46pm. The on scene assessment was carried out and both crew were safe and well but the vessel would need to be towed to Milford Haven. The tow was set up and the casualty vessel was under tow at 11:56pm.

The conditions were perfect for the slow tow back which saw a beautiful moon rising and the early glow of dawn.

Lifeboat arrived at Milford and swapped the casualty vessel to an alongside tow to take it alongside in to the lock at Milford Marina where the casualty was safely tied up at 04:49am.

The lifeboat rehoused at 05:15am where she got her well deserved washdown and the crew headed home to get some sleep.

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Meet the Pembrokeshire Mower Doctor

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A NEW Pembrokeshire business is proving to be an inspiration for young people after its recent launch.

The Pembrokeshire Mower Doctor is the brainchild of Ewan Griffiths, who turned his dream into reality thanks to the advice and support of Cam Nesa.

The project aims to reduce the number of young people aged 16-24 who are not in education, training or employment.

Before signing up to Cam Nesa, Ewan was out of work and struggling for direction, and anxiety was preventing him from maximising his potential.

Throughout his journey with Cam Nesa, Ewan worked closely with youth worker Donna Wright to devise a plan that provided support and guidance to improve his confidence and self-esteem, and provide mechanisms for coping with anxiety.

In addition, the project provided Ewan with opportunities to gain qualifications and obtain information that would help him with starting his own business.

Ewan’s message to other young people is simple, “If you find yourself struggling, there is help.”

“Cam Nesa supported me in all aspects of my plan, and working with Donna was fantastic.”

“I would definitely encourage others to reach out for support.”

Donna Wright, who supported Ewan throughout his Cam Nesa journey, said that the launch of his new business is a great source of pride for Cam Nesa and Pembrokeshire Youth Service.

“Ewan has come on leaps and bounds, and it was his engagement and determination that has made his outcome with Cam Nesa so successful and inspiring”, she said.

“Congratulations Ewan on your achievements, and we all wish you good luck with your new business.”

The Pembrokeshire Mower Doctor provides repairs and servicing for mowers, strimmers, hedge cutters, and most agricultural engines, with the mobile service providing collection and returns.

For more information, search ‘Pembrokeshire Mower Doctor’ on Facebook.

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Milford Haven: Mount estate death not being treated as suspicious say police

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POLICE have confirmed that following a welfare visit to a property in Mount Estate, they discovered a male occupant, in his 30’s, in need of medical help.

Despite the best efforts of medical staff he sadly passed away on Sunday.

A spokesperson for the police confirmed to The Pembrokeshire Herald: “Dyfed-Powys Police attended a property at the Mount Estate, Milford Haven on Friday 30th April 2021, following a report of concern for the welfare of the occupier.

“A male was taken to hospital where he died on Sunday 2nd May 2021.

“The death is not being treated as suspicious.”

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