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

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lost opportunitiesTHERE 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.

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Charity

Emergency food parcels in Wales top 170,000 as child hunger rises

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Trussell Trust warns of ‘wake-up call’ for government as 60,000 parcels go to children

MORE than 170,000 emergency food parcels were distributed across Wales last year by food banks in the Trussell Trust network—equivalent to one every three minutes. The charity says the scale of demand is a damning indictment of a broken welfare system and is calling on both the Welsh and UK governments to act urgently.

Of the 171,673 parcels issued between April 2024 and March 2025, over 60,000 were for children. That figure—60,158—represents a 16% increase in child food parcels compared to five years ago.

While the total number of parcels issued in Wales has fallen slightly—down 9% from the previous year—the Trussell Trust says need remains “persistently high” and warns that the situation for families is worsening. The number of parcels going to households with children has risen by 19% since 2019/20, with a notable 8% increase for children under five.

Many food banks are now reporting “heartbreaking” levels of hardship. Some parents are skipping meals to feed their children, while others are opening food parcels and eating immediately upon receiving them.

Andrew Butcher from Taff Ely Foodbank said: “We are witnessing a significant and growing number of individuals and families turning to our food bank for support—all struggling to afford the essentials. Sadly, food donations are not keeping pace with this increasing demand.
“No one should have to rely on charity to eat. While we remain committed to pushing for systemic change to eliminate the need for food banks altogether, community support remains vital.”

According to Trussell, over 420,000 people in Wales now face hunger and hardship. Disabled people remain disproportionately affected: three in four households referred to Trussell food banks report having at least one disabled member.

The charity is urging the next Welsh Government to commit to ending the need for emergency food as part of a wider anti-poverty strategy. This includes investment in affordable housing, improved access to employment and childcare, and a “cash-first” approach to financial crises.

Trussell is also calling on the UK Government to update Universal Credit to ensure all households can meet basic living costs. It has criticised proposals to cut disability benefits, warning such changes could push even more people into hardship.

Jo Harry, Trussell Trust’s Network Lead in Wales, said: “Thousands of children, families, disabled people, and older people across Wales relied on emergency food in the past year. A generation has now grown up seeing food bank use as normal.
“With Welsh elections less than a year away, all political parties must take a stand and commit to reducing the need for food banks.
“Ending hunger must be a priority if we want to improve public services, grow the economy, and build a better Wales.”

Members of the public can support local food banks by donating food or funds. To find out how many food parcels were distributed in your area, visit: campaign.trussell.org.uk/parcels-by-postcode

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News

Car fire closes Market Street in Haverfordwest

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FIREFIGHTERS were called to tackle a vehicle blaze in the centre of Haverfordwest on Monday afternoon (May 19).

The incident occurred at around 2:50pm on Market Street, where a car was reported to be alaze.

A crew from Haverfordwest Fire Station responded swiftly and brought the fire under control within half an hour. The road was temporarily closed while emergency services dealt with the situation.

A spokesperson for Mid and West Wales Fire and Rescue Service said: “At 2:51pm, firefighters from Haverfordwest attended a car fire on Market Street. The vehicle was well alight on arrival. One hose reel jet, a thermal imaging camera, small tools and a breathing apparatus set were used to extinguish the blaze.

“The crew left the scene at 3:24pm.”

No injuries were reported.

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Education

Excellent progress on the construction of new lower school building at Portfield School

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PUPILS from Portfield School have had the exciting opportunity to leave their mark on history as work continues at pace at their fantastic new school.

The pupils attended an event to mark the reaching of the highest point of the new building, traditionally known as the ‘topping-out’ ceremony. The event gave pupils a chance to sign one of the first steel beams, and leaving handprints on a wall, symbolising their role at the heart of the school community and the bright future ahead.

The event was hosted by Morgan Sindall Construction & Infrastructure Ltd and was attended by staff, pupils, governors, senior Council officers and officers from the project team to celebrate the key milestone.

Headteacher Sarah Hartley said: “We were thrilled to involve our pupils in this important moment. The new building represents a new chapter for Portfield School, and it’s wonderful that our children could be part of its foundations.”

The Council’s Cabinet Member for Education and the Welsh Language, Cllr. Guy Woodham, said that he was extremely pleased at the progress being made.

“Whilst I was unable to attend the event myself, my colleagues have shared with me their experience of the event, and the excellent progress being made on the new building at the school.

“This development will provide much needed modern, inclusive accommodation for the learners, and I am particularly pleased that the project remains on budget, and on programme, which means that Portfield School will be in a position to move into the building in December 2025.”

Following their visit, pupils made the following comments: “We had to wear protective clothing before entering the building site. Being able to write my name on one of the walls in the new building was really cool. I am very grateful to have been chosen to write my name in the new build it is extremely cool. Even though I am leaving this year my name will be there for ever.”

“Oh it was fun! I put my hand in paint and then put it on the wall.”

The project is being funded by Welsh Government and Pembrokeshire County Council as part of the Sustainable Communities for Learning Capital programme.

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