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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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Former Chequers nightclub to reopen

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AN APPLICATION for a new premises licence for the former Chequers night club succeeded at a meeting of Pembrokeshire County Council’s Licensing sub-committee on Thursday (Aug 22).

The former nightclub closed its doors for the last time in 2003, when it ran as a private members’ club, having had an application for a full on-licence rejected.

After failing in an attempt to close the club on that occasion, Pembrokeshire County Council became the only local authority in Wales to classify mobile homes as permanent residences in an effort to shut down the club once and for all.

The new applicant, Mrs Carmen Clemas applied for a new premises licence in respect of the club, which will be renamed the Queen of Clubs.

The Committee heard objections to the licence from local residents and heard representations from both the Police and Fire Service which pointed out that the building would need significant remedial works to it before it could re-open.

While Penally Community Council objected on the basis of events and problems at the premises almost twenty years ago, neither the Police nor Fire Service had an objection to the Club’s re-opening in principle.

Both emergency services emphasised that, even though they had no objections, they had concerns that had to be addressed.

The Committee granted the application, refusing permission for licensable activities at the Club on Sundays, apart from Sundays before Bank Holidays, and imposing strict noise control measures.

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St Davids RNLI to feature in new series of a popular TV documentary

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THE volunteer lifeboat crew of St Davids RNLI will be taking to the small screen next week as they will feature twice in the first episode of the BBC TV series Saving Lives at Sea.

Now in its fourth season the documentary series, which showcases the lifesaving work of the Royal National Lifeboat Institution (RNLI), will be aired on BBC Two on Tuesdays at 8 pm, as well as being available on the BBC iPlayer following the broadcast. The new 10-part series features real rescues carried out by the charity’s volunteer lifeboat crews and lifeguards around the UK and Ireland – including St Davids RNLI.

Each programme gives a unique insight into the lives and work of the charity’s lifesavers who are needed more than ever before, rescuing thousands of people and saving hundreds of lives around our coastline and on inland waterways every year. The new series features more dramatic real-life rescue footage, accompanied by emotive testimonials from the volunteer crews, lifeguards and the people they rescue and their families.

This forthcoming episode, on 27 August, sees St Davids RNLI launch to a crashed plane in one shout, and tow a yacht stranded in a shipping lane in another. These shouts are shown alongside rescue stories from their colleagues at other stations and beaches around our coasts.

Judd Kohler, Station Mechanic at St Davids Lifeboat Station, said: “The first episode of Saving Lives at Sea shows two very different shouts that St Davids RNLI responded to. The programme is a great chance for RNLI supporters to catch a glimpse of the work that their kind donations go towards. We want to say a huge thank you to supporters of the RNLI, who help us to save lives at sea.”

Filming took place over the past year, with lifeboat crews and lifeguards carrying special cameras and welcoming film-makers into their day-to-day life. Rescues from the RNLI’s archives are also revisited, and we get a glimpse into the everyday lives of the thousands of men and women who give up their time to save lives.

Last year alone, RNLI lifeboat crews around the UK and Ireland rescued 9,412 people, saving 211 lives, while the charity’s lifeguards aided 32,207 people and saved 118 lives on some of the UK’s busiest beaches.

Saving Lives at Sea begins on Tuesday 27 August at 8 pm on BBC Two, and will continue throughout August, September and October.

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Pembrokeshire schools celebrate GCSE results

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PEMBROKESHIRE’S schools are celebrating students’ success in this year’s GCSE exams.

 

“On behalf of staff and governors at Milford Haven School, I would like to congratulate all Year 11 pupils on their GCSE results, reflecting the efforts and commitment they have shown over the last two years and also thank their parents/carers for their support and cooperation,” said the Head Teacher, Ceri-Ann Morris.

 

“We are pleased with a number of individual successes, in particular, our top performers include, Izzy-May Solomon (10A*, 3A’s and B), Megan Owens (12A* and A), Megan Clarke (8A* and 4A’s), Finlay Ryder, Gareth Maclachlan, Evan Price, Molly Griffiths, Elanor Evans, Beth Lewis and Lucie Mathias.

 

The school is pleased to say that all pupils left school with qualifications which will help support them to follow the path of their choice, whether that be into the sixth form, college, apprenticeships or employment.

 

We wish you all good luck in your future careers.”

Among those receiving their results was Joseph Jenkins, a 14-year-old Year 9 student, who achieved a Distinction in Advanced Mathematics.

At Ysgol Y Preseli 100% of pupils achieved qualifications equivalent to 5A*-G; 91% 5A*-C and 37% achieved at least 5A*-A grades.

Across the core subjects, the pupils achieved the following results at A*-C – Welsh 86%; English 91%; Mathematics 82%; Science 84%.

The Head Teacher, Mr Michael Davies, commenting on the results stated: “We are very proud of all the young people who have worked tirelessly to achieve these results. I would also like to thank the staff for their willingness to go the extra mile to ensure that all pupils fulfil their potential at Ysgol y Preseli.”

Amongst the top performers were: Seren Allen – 13 A*, 1 A; Nuala Camplin – 8 A*, 4 A, 2B; Cerys Chadwick – 14 A*; Annest Davies – 6 A*, 4 A, 1B; Thomas Elliott – 9 A*, 4 A, 1 B; Gethin Greenhalgh – 9 A*, 5 A; Cara James – 5 A*, 8 A; Casey Lambert- 7 A*, 7 A; Alexander Larsen – 10 A*, 4 A; Tom Palfrey – 9 A*, 3 A, 1 B; Kate Thomas – 5 A*, 5 A, 3 B; David Varney – 7 A*, 4 A, 3 B
Education Minister, Kirsty Williams, has congratulated GCSE students on their results, as overall performance across Wales has improved.

This summer’s results mark the end of the significant GCSE reform journey undertaken in Wales. The last seven of reformed GCSE subjects are awarded this year including History, Computer Science and Welsh Second Language.

Speaking during her visit to King Henry VIII School in Abergavenny, Kirsty Williams said: “Today we have seen an improvement in overall performance across Wales. I would like to congratulate all learners receiving their results today and to thank the teachers who have worked so hard to deliver these new qualifications.

“Last year we saw a dramatic increase of 50% in entries for science GCSEs. I am pleased to see that entries and results are continuing on the upward trend, with more pupils gaining A*-C and more achieving the very top grades in Biology, Chemistry and Physics.

“This increase in learners being entered means more young people are accessing qualifications that lead to greater opportunities for further science study and careers, paving the way for the future scientists of Wales.”

Following the publication of yesterday’s GCSE and Welsh Baccalaureate results David Evans, Wales Secretary of the National Education Union said: “We congratulate all students who have collected their GCSE and Welsh Baccalaureate results from today and wish them all the very best for the future. It is particularly pleasing to note that overall GCSE performance in Wales has improved by 1.2% especially given the fact that all examinations have been subject to reform in recent years. This progress is a testament to the time and effort put into their studies by pupils across Wales and the unstinting dedication of education professionals in our schools.”

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