Narrative verdict in baby Rohan Rhodes inquest

Coroner Maria E.Voisin points to "lost opportunities" which to provide the baby with medical care.

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Trust: new safety checks in place since Rohan death

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.

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.

– Bryony Strachan, University Hospitals Bristol NHS Foundation Trust
  1. Richard Morgan

Narrative verdict in Rohan Rhodes inquest

"Rohan Rhodes was an extremely premature baby who was at risk of developing NEC" said coroner Maria E.Voisin.

"He developed this condition which caused his death on the 30th of September."

"On 29th September there were three occasions where he should have had a blood gas test. It's not known what the results would have been but there were lost opportunities which may have resulted in him receiving earlier medical care."

The coroner recorded a narrative verdict.

Rohan Rhodes was born 14 weeks early

Flax Bourton Coroners Court heard the medical team planned 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.

His condition failed to stabilise and he died, aged 36 days.


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