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.
News
Tigers second division Cup Champions
In a thrilling Pembrokeshire Division Two Cup final under the floodlights of Bridge Meadow Stadium, fans witnessed an epic battle between Monkton Swifts reserves and Johnston. Despite Monkton Swifts reserves being touted as favorites, Johnston proved their mettle from the outset.
The game kicked off with a burst of energy as Johnston’s center half, Craig Bendall, seized an early opportunity to put his team ahead just ten minutes into the match. However, Monkton Swifts’ prolific Scotsman, Davis, swiftly responded with an equalizer, showcasing the resilience of the favourites.
The momentum shifted again when the dynamic duo of Alfie and Scott Crawford of Johnston orchestrated a beautifully executed goal, putting Johnston back in the lead at 2-1.
As the game progressed, Monkton Swifts brought in reinforcements, including Ben Steele, to regain control. Their efforts paid off when Jordan Kilby leveled the score at 2-2 with just under 20 minutes remaining.
But the Crawfords had other plans. Combining once more, Scott provided the assist for Alfie, who coolly finished to put Johnston ahead once again.
With time running out, Monkton Swifts launched a relentless onslaught in search of an equalizer. However, Johnston’s defense held firm, defying the odds to clinch the Division Two Cup title in a memorable victory.
The match showcased the passion and determination of both teams, with Johnston emerging as deserving champions in a fiercely contested final at Bridge Meadow Stadium.
Crime
Police investigating attempted burglary at Haverfordwest shop
POLICE in Pembrokeshire are investigating an attempted burglary at No.37 Food and Wine shop on High Street, Haverfordwest, at about 3am on Wednesday, April 3.
A window was smashed and the door handle broken.
Police said: “If you have any information that could help enquiries, please get in touch with PC 195 Tayler, either by: https://bit.ly/DPPContactOnline, by emailing [email protected], or by calling 101.
“Alternatively, contact the independent charity Crimestoppers anonymously by calling 0800 555111, or visiting crimestoppers-uk.org.”
News
Don’t forget to vote on Thursday, May 2
THURSDAY, May 2 is your chance to vote for the Dyfed-Powys Police and Crime Commissioner.
Don’t forget to use your vote and head to your local polling station between 7am and 10pm.
They are elected by the public to hold Chief Constables and the police force to account on their behalf.
A Police and Crime Commissioner’s job is to set the police budget and make sure it is spent effectively, appoint the local police forces Chief Constables, set police and crime plans in collaboration with residents and work closely with the local council and other organisations on these plans.
This is the first election in Wales where you will need photographic ID to vote.
Accepted forms of ID include a UK, European Economic Area (EEA) or Commonwealth passport or drivers’ licence; and some concessionary travel passes, such as an older person’s bus pass or an Oyster 60+ card. Voters will be able to use expired ID if they are still recognisable from the photo.
Or you may have applied for a Voter Authority Certificate which is also accepted.
If you plan on taking your Postal Vote to a polling station or County Hall main reception remember to fill in a vote return form. Without the completed form those postal vote(s) will be rejected.
You can only hand in your own postal vote, and postal votes for up to five other people.
You can find out more about the Police and Crime Commissioner Elections online (opens in new window).
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