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

Questions raised over delayed west Wales express coach as FOI row deepens

Published

9 hours ago

March 27, 2026

Tom Sinclair

Concerns mount over transparency after Transport for Wales delays response on key documents

QUESTIONS are being raised over the future of a long-promised express coach service linking north and south west Wales, after a Freedom of Information (FOI) request triggered a delay by Transport for Wales.

The proposed express route between Bangor and Carmarthen was identified in a Welsh Government-backed business case in early 2025 as a key project capable of cutting journey times by up to 90 minutes.

However, more than a year after a public consultation was held, there has been no clear update on funding, delivery, or timelines.

Now, a detailed FOI request submitted to TfW is seeking answers — including business case documents, internal communications, and consultation results — but the transport body has said it needs more time to respond.

FOI delay sparks concern

In a reply dated Friday (Mar 27), TfW said it was relying on Section 43 of the Freedom of Information Act, which relates to commercial interests, and that it required additional time to carry out a public interest test.

The authority has indicated it will respond fully by April 28.

But the applicant, Dr John McTighe, has challenged that position, arguing that most of the requested information — including meeting dates, consultation documents, and performance data — cannot reasonably be considered commercially sensitive.

He has warned that failure to provide the non-sensitive material promptly could result in a referral to the Information Commissioner’s Office.

Contrast with north Wales rollout

The FOI request also highlights the introduction of the TrawsCymru T51 service between Wrexham and Rhyl, which was launched in 2025 and is set to receive a fleet of new vehicles this year.

Critics argue that while the north Wales route has progressed quickly, the west-coast express proposal — described as a “headline ambition” for improving north–south connectivity — appears to have stalled.

The Herald understands that the Bangor–Carmarthen route was backed by a positive business case and formed part of wider plans to improve long-distance public transport links across Wales.

Transparency questions

The request seeks details of meetings, internal correspondence, and consultation analysis — including the results of a public consultation which TfW said would be assessed using specialist software.

It also asks for information on how passenger numbers and performance data are monitored across the TrawsCymru network.

Concerns have been raised that key performance data, including annual passenger figures and punctuality statistics, are not routinely published in full.

Calls for clarity

The delay has prompted fresh calls for transparency over how decisions are made on publicly funded transport services in Wales.

There is particular concern in west Wales that strategic investment may not be progressing at the same pace as elsewhere, despite longstanding commitments to improve connectivity along the western corridor.

A spokesperson for Transport for Wales said the organisation is considering where the balance of public interest lies before releasing the requested information, and confirmed a full response will be issued by April 28.

The Welsh Government has been approached for comment.

Local Government

Oil spill alert after pollution hits Pembroke stream and Castle Pond

Published

9 hours ago

March 27, 2026

Tom Sinclair

Heating oil believed to have entered water via culvert as investigation and clean-up continue

AN UGENT investigation is underway after a suspected heating oil spill contaminated the Commons Stream and spread into Castle Pond in Pembroke.

Pembroke Town Council first raised the alarm, warning residents of a potential pollution incident affecting the watercourse. Officers from Pembrokeshire County Council’s Pollution Control Team and Natural Resources Wales are now on site working to identify the source and contain the spill.

Further information from local county councillor Aaron Carey suggests the oil likely entered the stream through a culvert near Foundry House, indicating the source may lie somewhere to the south of that location.

The substance is believed to be domestic heating oil. It is not yet known whether the spill was accidental or the result of a possible attempted fuel theft.

Residents in St Daniel’s Hill, South Road and Orange Gardens are being urged to check their heating oil tanks for any signs of damage or unexplained loss.

Witnesses reported seeing a blue-green sheen on the water near the castle side earlier today, raising concerns about the extent of the contamination.

Clean-up efforts are ongoing, and members of the public may notice increased activity around the stream and pond while teams work to manage the incident.

Anyone with information or concerns is advised to contact the relevant authorities.

News

Reform UK candidate quits days after Nazi salute row

Published

9 hours ago

March 27, 2026

Tom Sinclair

Corey Edwards stood in Pen-y-bont Bro Morgannwg and appeared at national hustings shortly before stepping down

REFORM UK Senedd candidate Corey Edwards has stepped down from the upcoming election, just days after controversy over a photograph appearing to show him making a Nazi salute.

The party confirmed on Thursday (Mar 27) that Edwards had withdrawn from the race, citing mental health issues. A spokesperson said: “Corey Edwards has informed us that he is stepping down as a candidate for the Senedd election this May, citing issues with his mental health.

“We wish him well for the future and hope his privacy can be respected at this difficult time.”

Edwards had been selected as Reform UK’s lead candidate for Pen-y-bont Bro Morgannwg, meaning he was in a strong position to be elected if the party secured a seat in the constituency.

His withdrawal comes shortly after a photograph emerged, first published by Nation.Cymru, which appeared to show him performing a Nazi salute. Edwards said the image, taken in 2019, could be “misinterpreted” and claimed he had been imitating either a scene from Fawlty Towers or Welsh footballer Wayne Hennessey, who was previously involved in a similar controversy.

Reform UK leader Nigel Farage said the image “looked terrible” but confirmed Edwards would not be removed as a candidate at the time, describing him as “a human being” and referencing the sitcom scene as context.

Edwards had also appeared publicly as a Reform representative at a national youth hustings event in Cardiff on Thursday (Mar 19), alongside politicians from other major parties.

In a statement, Edwards said: “Like many young people, I have made mistakes. But I am proud of the person I am today and the values I stand for.”

The Herald understands that Reform UK has not yet confirmed whether a replacement candidate will be selected for the constituency.