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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

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