Series of errors caused fatal baby gas mix-up in Sydney hospital
An oxygen mix-up at a western Sydney hospital that killed one baby and seriously injured another was caused by the incorrect installation of gas pipelines, flawed testing and governance failures, a report has found.
A baby boy died and a newborn girl suffered suspected brain damage after they were mistakenly given nitrous oxide or "laughing gas" instead of oxygen at Bankstown-Lidcombe Hospital in June and July.
A final report released on Saturday by NSW Chief Health Officer Dr Kerry Chant found "a series of tragic errors" led to the incidents.
Babies were given nitrous oxide instead of oxygen.
Dr Chant said she hoped the report would give the families of the two babies some answers, while conceding she couldn't begin to imagine how they must feel.
"I can imagine that whilst giving some of the answers the families must require, it still doesn't undo what's been done, the catastrophic impact this error has had," Dr Chant told reporters in Sydney on Saturday.
"We've certainly let them down and we should have done better."
The report found that South West Sydney Local Health District, and BOC Ltd which installed the medical gas piping, failed to comply with Australian standards.
It also unearthed broader clinical and governance issues around risk management, communication and lines of accountability.
The Health Ministry has been directed to further examine the governance issues and take over a disciplinary investigation already under way.
The general manager of the hospital has been suspended following investigations, after an engineer at the hospital was suspended earlier this month.
The Bankstown-Lidcombe Hospital.
Further interviews are taking place in relation to the investigation.
Dr Chant would not say whether either employee would face the sack, saying they deserved procedural fairness while the probe was under way.
The South Western Sydney Local Health District will also be placed on "performance watch".
NSW Health will now require different contractors carry out the installation and testing of gas pipelines.
Medical gas outlets in all other NSW health facilities have since been tested and no other failures found.
Health Minister Jillian Skinner did not appear before the media when the report was released.
Dr Chant would not say why Ms Skinner decided not to attend the press conference alongside her, nor would she comment on the minister's handling of the fatal failure.
The gas set up inside a theatre room. Source: 7News
In a brief statement, Ms Skinner said the public could be assured the health system was safe.
"As the Chief Health Officer's report shows, NSW Health has checked gas pipelines and there have been no other incorrect installations," she said.
"The Ministry of Health will accept all recommendations raised in the Chief Health Officer's final report to ensure this tragic error can never happen again."
News break – August 27
