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.

Charity

Bassetts Motor Group donates electric van to support lifesaving charity

Published

40 minutes ago

March 28, 2026

Tom Sinclair

BASSETTS Motor Group has donated an electric van to support the vital work of Wales Air Ambulance, providing a major boost to the charity’s day-to-day fundraising operations.

The South West Wales-based company has gifted a Citroën e-Berlingo for use until the end of the year — marking the first time the business has made a significant gift in kind to the charity.

Staff from Bassetts recently visited the charity’s headquarters in Dafen to hand over the vehicle, where they met with a medic and were given an insight into the critical care delivered by the service, including a tour of a rapid response car.

Ashley White, of Bassetts Motor Group, said: “Being a South West Wales-based business, we’ve seen first-hand the incredible work that Wales Air Ambulance does.

“We knew the charity relies heavily on fundraising and donations, so when we were looking for a cause to support, it felt like a natural choice.”

The van has been branded with the charity’s logo and information on how the public can support its lifesaving lottery.

Explaining the choice of vehicle, Ashley added: “We’re strong advocates of electric vehicles. Getting people behind the wheel often changes perceptions and helps overcome misconceptions about going electric.

“Citroën offered us a deal that made it possible for us to provide the van in this way, and we felt it would be perfectly suited to the charity’s fundraising needs.”

The Wales Air Ambulance delivers consultant-led emergency care across the country, bringing hospital-level treatment directly to patients and, where necessary, transferring them swiftly to the most appropriate specialist centres. This approach can save critical time and significantly improve survival and recovery outcomes.

The service operates through a unique partnership between the charity and the NHS, with the Emergency Medical Retrieval and Transfer Service providing highly skilled consultants and critical care practitioners who work onboard its aircraft and rapid response vehicles.

As a pan-Wales service, its crews cover the entire country, delivering emergency care wherever it is needed.

Nina Rice, Head of Fundraising High Value Partnerships at Wales Air Ambulance, said: “We are incredibly grateful to Bassetts Motor Group for this generous gift in kind.

“The use of the electric vehicle will make a real difference to our fundraising efforts, helping us reach more communities and raise vital funds.

“As a local company, Bassetts understands just how important our service is to people across Wales. This support will directly help us continue our lifesaving work.”

The charity must raise £13 million every year to keep its helicopters in the air and its rapid response vehicles on the road.

For more information, visit the Bassetts Motor Group website.

Community

Residents return home after major Carmarthenshire fire as probe continues

Published

1 hour ago

March 28, 2026

Tom Sinclair

RESIDENTS forced to evacuate their homes following a major fire in Kidwelly have now been allowed to return, as emergency services confirm the scene has been stood down.

The blaze broke out at a property on Lady Street in the early hours of Tuesday (March 24), with emergency services called at around 4:20am. Several neighbouring homes were evacuated as a precaution while firefighters tackled the incident and assessed the safety of surrounding buildings.

In the latest update, Dyfed-Powys Police confirmed that officers have now left the scene and displaced residents were able to return to their properties on Thursday evening (March 26), following work to make the affected building safe.

The incident caused significant disruption in the town, with Lady Street remaining closed while further work is carried out to ensure the safety of the highway and surrounding structures.

Emergency services, including Mid and West Wales Fire and Rescue Service, were on the scene for several hours during the initial response. Crews were understood to have dealt with a serious property fire, prompting a large-scale emergency operation in the centre of the town.

While the immediate danger has now passed, authorities have confirmed that investigations into the cause of the fire are ongoing. Police are continuing to appeal for witnesses or anyone with relevant information to come forward.

Officers are particularly keen to hear from anyone who may have CCTV, doorbell, or dashcam footage from the area between 11:00pm on Monday (March 23) and 4:00am on Tuesday (March 24).

Anyone with information is urged to contact police quoting reference 027 of 24/3, either via 101, online, or anonymously through Crimestoppers.

Authorities thanked residents and the wider community for their patience during the incident, which saw homes evacuated and roads closed while emergency services carried out their work.

Further updates are expected as the investigation progresses.

Community

West Wales fire crews sharpen skills in major training exercise

Published

2 hours ago

March 28, 2026

Tom Sinclair

FIREFIGHTERS from across west Wales took part in a large-scale training exercise designed to sharpen operational skills and strengthen teamwork.

Crews from the Western Division of Mid and West Wales Fire and Rescue Service attended the development day at Earlswood Training Centre on Sunday (March 22).

Personnel travelled from stations including Carmarthen, Tumble, Newcastle Emlyn, Milford Haven, Narberth and Pontyates to take part in the exercise.

Realistic scenarios

Firefighters were put through a series of realistic scenarios designed to reflect incidents they may face on duty.

These included house fires with people reported inside, kitchen fires, and multi-vehicle road traffic collisions. Crews also carried out specialist line rescue exercises as part of the day.

Support staff played the roles of casualties and members of the public, adding to the realism and allowing firefighters to test their responses in lifelike conditions.