The coroner says there were "lost opportunities" in the care of a premature baby who died after being removed from a ventilator.
A nurse at the inquest into the death of premature baby Rohan Rhodes at St Michael's Hospital in Bristol hospital has given evidence.
The parents of baby Rohan Rhodes have told the inquest into his death that his ventilator was removed too soon by hospital staff in Bristol.
University Hospitals Bristol NHS Foundation Trust says it offers "**sincere condolences" to Rohan Rhodes’ family.
We hope that the inquest has helped to answer their questions about why Rohan died.
The Coroner's narrative conclusion reflects the sad situation that Rohan was an extremely premature baby and therefore at risk of developing the serious bowel condition from which he ultimately succumbed.
The trust says it has put in place 'clear requirements' for blood gas measurements in babies on respiratory support and has implemented a system of safety checking for medical and nursing staff looking after individual babies.
– Bryony Strachan, University Hospitals Bristol NHS Foundation Trust
St Michael’s Hospital has an outstanding Neonatal Intensive Care Unit (NICU), offering the most advanced care and support to babies and families. However, the Coroner has identified that there were missed opportunities to perform a particular test during Rohan's admission, specifically three blood gas measurements.
The Coroner has confirmed that what those results would have been remains unknown, but we are very sorry that those three checks were missed, within continuous monitoring of Rohan's critical condition within NICU.
The Coroner in the inquest of baby Rohan Rhodes, who died at St Michael's Hospital, says there were "lost opportunities" in his care.
Rohan, who was born 15 weeks premature in Wales, died after being removed from a ventilator after being transferred to St Michael's in Bristol.
Flax Bourton Coroner's Court heard the medical team's plan was to keep Rohan on the ventilator ahead of upcoming heart surgery.
But advanced neonatal nurse Amanda Dallorzo took the "autonomous" decision to remove the machine and put a breathing mask on Rohan instead.
His condition deteriorated and he developed NEC, a gastrointestinal disease, which required surgery.
He never became stable for the operation and he died, aged just 36 days.
Avon Coroner Maria Voisin recorded a narrative verdict following a three day inquest into Rohan's death.
– Avon Coroner Maria Voisin
Rohan Rhodes was an extremely premature baby who was at risk of developing NEC.
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.
A victim of the heart babies scandal at Bristol hospitals has been awarded half a million pounds in compensation.
The man in his 20s, who can't be named, was left with lifelong disability after a specialist at Bristol Children's Hospital failed to diagnose the heart defect he had as a baby.
The pay out was approved by a judge at the High Court. More than 30 babies died and dozens more were left with brain damage after failures by doctors in the late 1980s and early 90s.
When the Bolton footballer Fabrice Muamba collapsed on the pitch last month there was some surprise that someone so apparently healthy could succumb to heart disease. But every week in the UK, 12 young people die unexpectedly from similar conditions.
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