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Narrative verdict in Rohan Rhodes inquest

Rohan Rhodes died after being transferred to St Michaels hospital, Bristol, for heart surgery Photo:

The Coroner in the inquest of a baby who died at St Michael's Hospital in Bristol, says there were "lost opportunities" in his care.

A narrative verdict was recorded following the three day inquest.

Bryony Strachan, clinical chair of the Division of Women's and Children's Services at University Hospitals Bristol NHS Foundation Trust, offered the family its condolences.

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.

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.

We have already put in place clear requirements for blood gas measurements in babies on respiratory support and have implemented a system of safety checking shared by both medical and nursing staff looking after individual babies.

– Bryony Strachan, clinical chair of the Division of Women's and Children's Services at University Hospitals Bristol NHS Foundation Trust

From Flax Bourton, Richard Morgan sent this report:-

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