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.

Crime

Emergency bags rolled out to support domestic abuse victims across Dyfed-Powys

Published

5 hours ago

December 19, 2025

Tom Sinclair

Thirty packs provide immediate help for families fleeing dangerous situations

A NEW initiative aimed at supporting victims of domestic abuse has seen thirty emergency bags distributed for use across the Dyfed-Powys Police area.

The bags, which contain essential items including toiletries, non-perishable snacks and emergency supplies, are designed to offer immediate practical support to individuals and families forced to flee abusive situations, often with little or nothing.

The scheme forms part of the Police and Crime Commissioner’s wider commitment to improving outcomes for victims and is being delivered in partnership with Dyfed-Powys Police and Dal i Godi, the commissioned Independent Domestic Violence Adviser (IDVA) service.

Dal i Godi provides specialist support to victims at high risk of serious harm, including safety planning and advocacy through the criminal justice process.

Police and Crime Commissioner Dafydd Llywelyn said the initiative was already proving its value.

“This is an incredible initiative that I’m proud to support,” he said. “It provides meaningful help to those experiencing trauma and reflects our ongoing work to put victims first.

“Within just a few days of the bags being distributed to the Dal i Godi service, one was given to a victim fleeing a domestic abuse situation, along with a children’s pack to support their young family. That shows just how essential this support can be and how quickly it can make a difference.”

Detective Chief Inspector Llyr Williams, from the Dyfed-Powys Police Vulnerability Hub, said the emergency bags could provide a vital lifeline at critical moments.

“These emergency bags offer support at some of the most difficult moments in a person’s life,” he said.

“The contents provide immediate comfort, dignity and practical help for those leaving their homes in crisis. While simple, they represent an important first step towards safety and recovery.

“We are proud to be working with partners across the Dyfed-Powys area to ensure this support reaches people when they need it most.”

Anyone experiencing domestic abuse, or concerned about someone else, is encouraged to seek help. In an emergency, call 999.

Domestic abuse can also be reported online via Dyfed-Powys Police.

Support services available include Victim Support Dyfed-Powys, which offers free and confidential help to anyone affected by crime, whether or not it has been reported, and Dal i Godi, which provides specialist IDVA support for high-risk victims.

The Live Fear Free Helpline offers 24-hour support for those experiencing domestic abuse or sexual violence across Wales.

If you or someone you know is a victim of domestic abuse, please consider reporting it. If you are in danger or need support right away, please call 999.

You can report domestic abuse through the online crime reporting service here: Report domestic abuse | Dyfed-Powys Police.

Support is also available via the below support services:

Victim Support Dyfed-Powys

Free, independent support for anyone affected by crime in the Dyfed-Powys area, whether or not it has been reported to the police.

0300 123 2996

Victim Support Dyfed-Powys

Dal i Godi (IDVA Service)

Specialist support for victims of domestic abuse at high risk, offering safety planning, emotional support, and advocacy with agencies such as police and courts.

01267 221194

Dal i Godi

Live Fear Free Helpline

24/7 support for anyone experiencing domestic abuse or sexual violence.

0808 80 10 800 | Text 07860 077333

[email protected]

News

Welsh-language school praised for ‘happy, proud and friendly community’

Published

6 hours ago

December 19, 2025

Tom Sinclair

Estyn highlights strong leadership, positive attitudes and a clear curriculum vision at Ysgol Bro Preseli

A WELSH-medium all-age school in Crymych has been praised by inspectors for fostering a “happy, proud and friendly community,” according to a recent Estyn report.

Inspectors said pupils at Ysgol Bro Preseli show pride in their local area, thrive both academically and socially, and are well prepared for the next stages of their learning.

The school currently has 932 pupils on roll, including 118 in the sixth form, and has operated as an all-age school since 2022.

Estyn found that most pupils demonstrate extremely positive attitudes to learning, treat staff with respect, and listen carefully to the contributions of their peers.

The report also notes that, in almost all cases, teachers show strong subject knowledge. Inspectors highlighted the close and supportive relationships staff build with pupils, alongside the creation of a safe learning environment where pupils are not afraid to make mistakes.

It states: “As a result of a clear strategic direction and detailed planning, teachers provide beneficial practical activities that allow pupils to develop purposeful oracy, reading and writing skills in language sessions and across the other areas of learning and experience.”

Inspectors also praised the school’s clear curriculum vision, rooted in its motto Gwreiddiau a Gorwelion (Roots and Horizons).

“Leaders and teachers provide a coherent curriculum and learning experiences that bridge the primary and secondary sectors effectively,” the report said. “Staff plan stimulating activities and experiences for pupils to learn and deepen their understanding within the areas of learning and experience. This contributes positively to the sense of belonging that permeates the whole curriculum of Ysgol Bro Preseli.”

Headteacher Rhonwen Morris said the report was a reflection of the collective effort across the school community.

“As a successful all-age Welsh-medium school, we are delighted that the report recognises our commitment to excellence and the unique identity that makes Ysgol Bro Preseli so special,” she said.

“Since becoming an all-age school in 2022, our cohesive leadership team and governing body have focused on building a strong foundation based on our values of Welsh ethos, kindness, community and responsibility.

“The report highlights the excellent strategic work of staff at all levels, which is a testament to the shared dedication and vision that drives our school forward.

“It is gratifying that the report reflects what we continuously aim to achieve day in and day out. This achievement belongs to our entire community — staff, pupils, parents and governors — and together we will continue to build on this success and provide the very best education for every pupil.”

Charity

Welsh opticians raise £1,600 for people experiencing homelessness

Published

6 hours ago

December 19, 2025

Tom Sinclair

SPECSAVERS Pembroke Dock has helped raise £1,600 to support people experiencing homelessness this winter, with all funds going to The Wallich’s winter appeal.

Thirteen stores from North, South and West Wales donated £1 for every customer feedback form completed during November to help The Wallich, Wales’ largest homelessness and rough sleeping charity, continue its vital work.

Supporting more than 8,000 people experiencing or at risk of homelessness across the nation each year, The Wallich runs around 100 diverse projects across 20 local authorities to provide hope, support and solutions to end homelessness.

Funds raised by Specsavers will go directly to the Wallich’s Flexible Assistance Fund, which provides small but vital emergency grants. The grants support people at crucial turning points, helping cover essential costs such as phone credit, rent or food shops.

This initiative is a continuation of Specsavers’ wider homelessness programme, which sees over a hundred Specsavers stores and Home Visits services hold out-of-hours or pop-up clinics and invite people affected by forms of homelessness to use their services for free.

Specsavers’ North Wales regional relationship manager, Martin Lawrence, who helped organise the fundraiser, says: ‘We’re really proud to be supporting The Wallich’s winter appeal at a time when support is needed most.

‘Homelessness affects people in every community and as locally owned and run businesses, Specsavers stores are committed to raising awareness of the issue and supporting people through their toughest moments.

‘We’re excited to build on the success of this fundraiser and strengthen our partnership with The Wallich in the new year.’

Louisa Turner, head of fundraising at The Wallich, adds: ‘Winter can be an incredibly difficult time for people experiencing homelessness and this support from Specsavers will make a real difference.

‘The funds raised will help provide emergency grants at critical moments – whether that’s putting food on the table, helping someone stay connected with their loved ones or preventing someone from losing a safe place to live.

‘This kind of support creates vital turning points and helps people move towards a safer, more secure future.’

Specsavers works year-round with homelessness charities including Crisis, Vision Care and The Big Issue, to improve access to healthcare and advocate for policy change – ensuring people experiencing homelessness can receive free eye tests, glasses and hearing checks.

To find out more about Specsavers or to book an appointment at your local store, visit: https://www.specsavers.co.uk/stores.