The Parents Of A Premature Baby Who Died At A Hospital In Bristol Have Called For Changes To Be Made

The parents of a premature baby who died at St Michael's Hospital in Bristol in 2012 have called for changes to be made at the facility.

Rohan Rhodes, of Narbeth in Pembrokeshire, died two days after he was admitted to the hospital and a coroner has concluded there were serious "lost opportunities" during his care at the site.

Maria Voisin, Avon Coroner, said Rohan was born 14 weeks early and was transferred to the Bristol-based hospital so an open heart duct, which normally closes at birth, could be closed, reports the Press Association.

Staff from the neonatal unit cried at the coroner's hearing as they were told of how they baby was meant to remain on a ventilator until after his surgery was completed, but a nurse removed him from it without consulting any of her superiors.

The healthcare assistant instead attached a breathing mask to Rohan, but within an hour the child appeared "blank" and "lifeless", before his heart rate dropped into the low 20s.

However, this was discovered and the child was moved back onto a ventilator so he could recover.

But the warm air in his incubator was then left switched off, allowing his temperature to drop to 33.6 degrees C.

Nurses then failed to carry out three blood gas tests on the child to see if he had suffered from being too cold and without air, something that might have left to his eventual death, which resulted from a number of cardiac arrests.

Speaking after the coroner's verdict, Rohan's parents Bronwyn and Alex Rhodes said: "When Rohan came under the care of St Michael's he was sick but he was a stable little boy. Within 48 hours of that transfer he was dead.
 
"Over the course of the inquest, we have heard evidence that the senior nurse was not authorised to remove Rohan from his ventilator and that this act seriously affected his chances of survival."

The baby's parents now want to see "systemic change" for the better at the hospital.

Expert Opinion

This is a truly tragic case and what makes it all the more heartbreaking is that it could have been avoided if various staff on the unit had made the necessary checks on Rohan’s safety during his treatment. <br/> <br/>“University Hospital Bristol NHS Trust must now consider how it was possible for such horrendous failings to occur and ensure every possible step is taken to ensure the same errors cannot happen again. <br/> <br/>“Sadly, this is not the only case we have heard of recently relating to failings in the care given to children and babies within this Trust and questions must be answered about why it is possible for repeated failings to happen. <br/> <br/>“Staff training and resource must be investigated to protect future patient safety and the lessons learned should be shared throughout the NHS to improve practise across the country.” <br/> Julie Lewis - Partner