News

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

Published

12 years ago

March 10, 2014

THERE 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.

Business

First wind turbine components arrive as LNG project moves ahead

Published

2 hours ago

December 4, 2025

Tom Sinclair

THE FIRST ship carrying major components for Dragon LNG’s new onshore wind turbines docked at Pembroke Port yesterday afternoon, marking the start of physical deliveries for the multi-million-pound renewable energy project.

The Maltese-registered general cargo vessel Peak Bergen berthed at Pembroke Dock shortly after 4pm on Wednesday, bringing tower sections and other heavy components for the three Enercon turbines that will eventually stand on land adjacent to the existing gas terminal at Waterston.

A second vessel, the Irish-flagged Wilson Flex IV, is due to arrive in the early hours of this morning (Thursday) carrying the giant rotor blades.

The deliveries follow a successful trial convoy on 25 November, when police-escorted low-loader trailers carried dummy loads along the planned route from the port through Pembroke, past Waterloo roundabout and up the A477 to the Dragon LNG site.

Dragon LNG’s Community and Social Performance Officer, Lynette Round, confirmed the latest movements in emails to the Herald.

“The Peak Bergen arrived yesterday with the first components,” she said. “We are expecting another delivery tomorrow (Thursday) onboard the Wilson Flex IV. This will be blades and is currently showing an ETA of approximately 03:30.”

The £14.3 million project, approved by Welsh Ministers last year, will see three turbines with a combined capacity of up to 13.5 MW erected on company-owned land next to the LNG terminal. Once operational – expected in late 2026 – they will generate enough electricity to power the entire site, significantly reducing its carbon footprint.

Port of Milford Haven shipping movements showed the Peak Bergen approaching the Haven throughout Wednesday morning before finally tying up at the cargo berth in Pembroke Dock. Cranes began unloading operations yesterday evening.

Weather conditions are currently favourable for this morning’s arrival of the Wilson Flex IV, which was tracking south of the Smalls at midnight.

The abnormal-load convoys carrying the components from the port to Waterston are expected to begin next week, subject to final police and highway approvals.

A community benefit fund linked to the project will provide training opportunities and energy-bill support for residents in nearby Waterston, Llanstadwell and Neyland.

Further updates will be issued by Dragon LNG as the Port of Milford Haven as the delivery programme continues.

Photo: Martin Cavaney

Crime

Banned for 40 months after driving with cocaine breakdown product in blood

Published

2 hours ago

December 4, 2025

Sarah-Jane Absalom

A MILFORD HAVEN woman has been handed a lengthy driving ban after admitting driving with a controlled drug in her system more than ten times over the legal limit.

SENTENCED AT HAVERFORDWEST

Sally Allen, 43, of Wentworth Close, Hubberston, appeared before Haverfordwest Magistrates’ Court on Thursday (Dec 4) for sentencing, having pleaded guilty on November 25 to driving with a proportion of a specified controlled drug above the prescribed limit.

The court heard that Allen was stopped on August 25 on the Old Hakin Road at Tiers Cross while driving an Audi A3. Blood analysis showed 509µg/l of Benzoylecgonine, a breakdown product of cocaine. The legal limit is 50µg/l.

COMMUNITY ORDER AND REHABILITATION

Magistrates imposed a 40-month driving ban, backdated to her interim disqualification which began on November 25.

Allen was also handed a 12-month community order, requiring her to complete 10 days of rehabilitation activities as directed by the Probation Service.

She was fined £120, ordered to pay £85 prosecution costs and a £114 surcharge. Her financial penalties will be paid in £25 monthly instalments from January 1, 2026.

The bench—Mrs H Roberts, Mr M Shankland and Mrs J Morris—said her guilty plea had been taken into account when passing sentence.

Local Government

Sewage leak at Pembroke Commons prompts urgent clean-up works

Published

4 hours ago

December 4, 2025

Tom Sinclair

Council pollution officers say they have no enforcement powers over Welsh Water infrastructure

SEWAGE contamination on the Commons in Pembroke has prompted an urgent response from pollution officers, after a leak was reported by a member of the public on Tuesday.

Pembrokeshire County Council’s Pollution Control Team confirmed they were alerted yesterday afternoon to sewage surrounding a manhole cover on the site. The Herald understands that officers immediately notified Welsh Water (DCWW) network technicians to investigate the incident “as a matter of urgency”.

County councillor Jonathan Grimes, who represents Pembroke St Mary South and Monkton, said the authority had been clear that it holds no enforcement powers over Welsh Water assets.

“Whilst we work constructively with Welsh Water, we have no authority to intervene on their apparatus or to carry out enforcement action against them for such pollution incidents,” the Pollution Control Team said in a statement shared with the councillor.

Urgent works underway

Council officers visited the site on Wednesday morning alongside contractors and Welsh Water technicians to assess clean-up options. According to the team, works will include cleaning the contaminated ground in and around the manhole cover and fencing off the affected area “until safe”.

Cllr Grimes said officers would return to the scene on Thursday to check on progress and ensure the area is properly secured.

Residents who notice any further issues have been urged to contact the Pollution Control Team directly.

Further updates are expected later this week.