News
Coroner says there were ‘lost opportunities’ in baby’s care
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.
Entertainment
Families urged to explore historic Wales this half term with low-cost Cadw days out
FAMILIES across Wales are being encouraged to rediscover history on their doorstep this February half term, with more than 130 historic sites offering affordable days out.
Cadw, the Welsh Government’s historic environment service, says its castles, abbeys and ancient monuments provide low-cost options for families looking to get out of the house without breaking the bank.
From dramatic medieval fortresses to Roman remains and peaceful abbey ruins, many locations are within easy reach of local communities, making them ideal for a short day trip.
Nearby highlights include Caerphilly Castle, Caernarfon Castle, Raglan Castle, and the Caerleon Roman Baths, each offering a mix of history, open space and hands-on activities.
Good value days out
New visitor research carried out by Cadw shows strong satisfaction among guests. More than 85 per cent rated their visit as good, while nearly two in five said their experience was better than expected.
Families are being encouraged to bring picnics, book tickets online in advance and consider membership options to keep costs down, particularly for repeat visits over school holidays.
History brought to life
Several sites now include improved interpretation and interactive elements aimed at younger visitors.
At Caerphilly Castle, recent restoration work has recreated parts of the medieval interior, allowing visitors to step inside spaces such as the Great Hall and gatehouse to see how the fortress would have looked in the thirteenth century.
Meanwhile, children visiting Caerleon can take part in a daily Roman Baths trail where they can touch, smell and explore objects linked to life in Roman Britain.
Quieter winter exploring
Cadw says winter can be one of the best times to visit, with fewer crowds and dramatic seasonal scenery.
Places such as Tintern Abbey, Chepstow Castle, Criccieth Castle, and Valle Crucis Abbey offer peaceful walks alongside striking historic backdrops.
Something close to home
With sites spread across the country, most families will have a Cadw monument within a short drive.
Membership options provide unlimited entry throughout the year, with children admitted free with adult members, alongside shop discounts and reciprocal offers at other UK attractions.
Further details on opening times, events and tickets are available at the Cadw website.
Local Government
Residents invited to step forward for town council roles
HAVERFORDWEST TOWN COUNCIL is inviting local residents to put themselves forward for two vacant councillor seats, with positions currently available in the Prendergast and Priory wards.
The vacancies will be filled by co-option after no election was called when the casual vacancies were previously advertised.
The Town Council area is divided into five wards – Castle, Garth, Portfield, Prendergast and Priory – and is responsible for managing a range of local facilities and services including recreational play and leisure areas, a sports changing facility and two cemeteries.
Council representatives say they are looking for people who are willing to commit time and energy to serving the community and helping shape decisions that affect the town.
Applicants should be practical, good communicators and able to work as part of a team. No previous council experience is required.
Co-opted councillors take part in meetings, help oversee local projects and represent the interests of residents in their ward.
The closing date for applications is February 27, 2026.
Anyone interested in applying, or wishing to have an informal discussion about the role, can contact the Town Clerk by emailing [email protected].
Further information is available at: www.haverfordwest-tc.gov.uk

Community
Community groups invited to apply for monthly funding boost from Cwm Arian
£200 donations helping sports clubs, warm spaces, schools and local projects keep Pembrokeshire villages connected and thriving
COMMUNITY groups across north Pembrokeshire are being encouraged to apply for monthly funding as Cwm Arian Renewable Energy continues its programme of small grants aimed at strengthening local life.
The community energy organisation is offering £200 every month to support grassroots projects, with the funding open to clubs, charities, volunteer groups and informal community initiatives. Since the scheme launched in April 2022, the fund has supported a wide range of activities, from youth sport and schools to cultural events and wellbeing projects.
The grants are deliberately flexible, allowing groups to decide what their communities need most rather than fitting strict criteria. Money can be used for hall hire, equipment, refreshments, transport, training costs or materials, helping even the smallest organisations get ideas off the ground.
In Hermon, funding has supported the popular Warm Rooms project, providing hot meals, company and a welcoming space for older residents during the colder months. Organisers say the grant has helped tackle isolation while giving people somewhere safe and social to meet.

In Crymych, football and rugby clubs have used the donations to run training sessions, organise matches and purchase kit, giving young people regular opportunities to stay active, develop skills and build confidence. Elsewhere, cultural groups and local festivals have used the support to stage workshops, performances and events that bring residents together.
A spokesperson for Cwm Arian said the aim is to keep the process simple and accessible.
They said: “These donations are about helping local people do what they already do best. A relatively small amount of money can make a big difference to a village group or volunteer project. We want to support activities that strengthen communities and improve everyday life.”
Best known locally for its renewable energy and sustainability work, Cwm Arian says reinvesting income back into the community is central to its mission.
Groups with an idea that benefits people in Pembrokeshire are invited to apply, with guidance and application details available through the Cwm Arian website.
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