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.

News

Cadw invites families to step into West Wales history this half-term

Published

2 hours ago

May 19, 2026

Tom Sinclair

STRATA Florida Abbey and Laugharne Castle will host family events as part of Cadw’s May half-term programme.

FAMILIES in West Wales are being encouraged to explore historic sites on their doorstep this May half-term, with events planned at Strata Florida Abbey and Laugharne Castle.

Cadw’s programme runs from Saturday, May 23 to Sunday, May 31, with activities across Wales aimed at bringing history to life for children and families.

At Strata Florida Abbey, near Pontrhydfendigaid, a craft fayre will take place on Sunday, May 24, from 11:00am to 3:00pm, featuring local arts, crafts and produce, alongside family-friendly activities and guided tours.

Laugharne Castle will host Rainbow Gecko Bubbleman on Saturday, May 30 and Sunday, May 31, from 11:00am to 4:00pm. Bubbleman and the Bubble Faerie will perform giant bubble displays, bubble animals and frozen creations, with visitors able to join in and learn tricks.

Other West Wales events include a Children’s Activity Day at Strata Florida Abbey and HMS Wales Naval Living History at Laugharne Castle.

Kate Roberts, Chief Executive of Cadw said: “May half term is the perfect chance for families to get out and explore the incredible history on their doorstep in Wales.

“This year’s programme has been designed to be hands-on, engaging and genuinely fun, giving visitors of all ages the chance to connect our nation’s past and spend quality time together outdoors.”

Cadw said membership includes free event entry and unlimited access to more than 130 historic places across Wales, with children going free with any adult membership.

Business

Mayor opens new Sapphire showroom in Milford Haven

Published

3 hours ago

May 19, 2026

Tom Sinclair

New Charles Street base brings windows and doors firm closer to Pembrokeshire customers

THE MAYOR OF MILFORD HAVEN has officially opened a new showroom for Sapphire Windows & Doors in the town centre.

The company welcomed visitors to its new base at 61 Charles Street on Monday (May 18), with Mayor Mark Woodward attending the opening.

Sapphire Windows & Doors, established in 1989, supplies and installs windows, doors and glazing products across South and West Wales.

The new Milford Haven showroom has been opened following growing demand from customers in Pembrokeshire, many of whom had previously travelled to the company’s Ammanford showroom.

The Charles Street premises will allow customers to view products in person, compare colours and finishes, try different styles, and speak directly with the Sapphire team.

Products on display include uPVC windows, composite and aluminium entrance doors, aluminium sliding and bifold systems, and internal and external Crittall-style aluminium and steel doors.

Shaun Matthews, Director of Sapphire Windows & Doors said: “We are incredibly excited to open our new Milford Haven showroom and welcome both returning and new customers through the doors.

“We have already received such a lovely welcome on Charles Street, and we are looking forward to becoming part of the local community.

“When people are investing in new windows and doors, it is important they feel confident in what they are choosing. The showroom gives customers the opportunity to properly see the products, explore the options available, try them for themselves and receive clear, honest advice from our team.”

The company manufactures its own uPVC products in-house at its factory in Ammanford, while installations are carried out by directly employed fitting teams.

Sapphire says it offers free, no-obligation quotes and takes a no-pressure approach to sales.

Every installation is backed by a ten-year guarantee and a FENSA insurance-backed warranty.

The new showroom is now open at 61 Charles Street, Milford Haven, SA73 1SA.

For more information visit sapphirewindows.info.

Community

Cardigan family’s urgent appeal after father suffers devastating stroke

Published

3 hours ago

May 19, 2026

Tom Sinclair

Former pilot left unable to speak or swallow after collapsing while mowing lawn

A CARDIGAN family has launched an urgent appeal for help after a 72-year-old father suffered a massive stroke while mowing his garden, leaving him unable to speak, swallow or move the right side of his body.

Les Bell collapsed on Monday, May 11, after suffering what doctors described as an intracerebral haemorrhage (ICH) – a serious form of haemorrhagic stroke caused by bleeding in the brain.

His daughter, Jessica Grieve, said the bleed was extensive and that her father remains in a critical condition on an acute stroke ward.

The former pilot, who now works as a flight training consultant at Gatwick Airport, is currently being fed through a tube and can only communicate through eye contact, small nods and grunts.

Jessica said: “Dad has lost the right-hand side of his body, has to be tube fed as he’s not conscious enough to perform a swallow test, although it would seem the muscles on the right side of his throat aren’t working.

“He can’t talk. He can only communicate with brief eye contact, small nods and grunts.”

She added that doctors are still unable to predict her father’s long-term prognosis.

“We don’t know the prognosis, only time will tell, but he is in a critical condition and it’s likely to remain that way for some months,” she said.

The family is now facing a financial crisis after Les, who was the main income earner, became suddenly incapacitated.

Jessica said her father managed all household finances, while her mother is unable to work due to disabilities and her brother, Jake, is still suffering the effects of cancer treatment and cannot work full-time.

She is now applying for lasting power of attorney in order to access her father’s bank accounts, but said the process could take up to ten weeks.

In the meantime, the family say they are struggling to pay rent, bills and other essential costs.