Baby death inquest

The Coroner at the inquest into the death of baby Rohan Rhodes, who died at St Michael's Hospital in Bristol, awaiting hear surgery, has recorded a narrative verdict.

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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


Baby death inquest:"lost opportunities" in care

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.

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.

– Avon Coroner Maria Voisin
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