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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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Drug drive arrest following routine check

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A MALE has been arrested following a positive roadside test.

The vehicle, which was stopped this morning, June 6, by the Pembrokeshire Road Policing Unit (Pembrokeshire RPU) was part of a routine check.

Traffic officers suspected the driver may be under the influence after smelling cannabis coming from the vehicle.

A roadside drug test was performed with a positive result with the drugswab provided. A small quantity of cannabis was also found inside the vehicle.

The cannabis was seized and the driver was arrested, later released under investigation, pending the male’s blood test result for the drug drive offence, out of court disposal for the possession.

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Campers from Cardiff sent packing

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PEMBROKESHIRE Road Policing Unit (Pembrokeshire RPU) have this morning, June 5, reported nine individuals for breaching coronavirus regulations.

The occupants of the three vehicles, all from the Cardiff area, had moved barriers that had been in place to close off the carpark to the public and set up camp for the night.

A Pembrokeshire RPU spokesperson said ‘Three vehicles from the Cardiff area located at Abereiddy this morning.

“The occupants of the vehicles, who’d travelled down overnight, had moved the barriers that had been used to close the car park. Having done so they then set up camp nearby.

“All nine persons present were reported for breaching coronavirus regulations. One was further dealt with by means of an out of court disposal for possession of cannabis.

“Rubbish cleaned up, car park closure reinstated, vehicles escorted out of Pembs.”

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Police urge visitors to ‘check the rules’

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POLICE in Powys are reminding people to check the rules before they travel, as tourists from the Midlands, London and Bristol continue to visit despite lockdown restrictions.

Last weekend more than 1,000 cars were turned around by police in the Brecon Beacons after visitors attempted to access the area around Ystradfellte known as ‘waterfall country’.

Many of those stopped claimed they thought the rules around travel were the same as in England, while others had deliberately flouted them.

Seventy-two per cent of people reported for breaches of Covid-19 restrictions in Powys since March 27 have been from outside the police force area.

“I would like to thank the communities of Powys for their cooperation in recent months in complying with requirements of the Covid 19 legislation and also reassure them we are still working hard with our partners to police the restrictions that remain in place across Wales,” said Superintendent Steve Davies.

“Our officers have worked hard to engage with the public at every opportunity throughout these unprecedented times by explaining what we are doing and why, and encouraging people to make the best choices to protect public health in Wales.

“But where people have clearly flouted the rules we have dealt with them appropriately and issued fines.”

He said officers will continue to conduct stop checks throughout Powys and across the force area this weekend.

In England, people can now travel an unlimited distance for exercise and to access so-called ‘beauty spots’.

But the Welsh Government has said people must remain local – ideally not travelling further than five miles from their home – for exercise or limited leisure pursuits, and this also applies to anyone travelling across the border.

Wales’ three national parks – which include popular sites such as Snowdon, the Elan valley and the Pembrokeshire coast – currently remain closed to the public, as do all National Trust car parks and properties.

The latest Welsh Government advice is available at gov.wales/coronavirus.

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