A hospital engineer has been stood down and the company that installed the system that delivered the wrong gas to two newborn babies at a Sydney hospital will have its contracts suspended as part of the NSW government response to the tragedy.
A baby boy died and a baby girl has been left with serious brain damage after nitrous oxide – commonly known as “happy gas” – was incorrectly connected to the oxygen outlet in one of the operating theatres at Bankstown-Lidcombe Hospital.
Engineer stood down over baby gassing scandal
A total of 36 babies were born in the operating theatre with affected gas outlets, a report by the Chief Health Officer found. Only two babies were treated in the resuscitation unit, where the gas was delivered.
NSW Health Minister Jillian Skinner faced the media on Tuesday to deliver the interim findings of an investigation into the fatal error, expressing her “profound sorrow and sympathy”.
Ms Skinner said she had personally apologised to both families and promised them her full support and compensation.
“A hospital engineer involved in the commissioning of the gas outlets … has been stood down,” Ms Skinner said.
The oxygen outlet was installed and certified by BOC Ltd in July 2015.
“I believe you’ll find BOC … will be found to be involved,” Ms Skinner said.
“It is my strong belief that BOC Ltd, which installed and certified the medical gas outlet and Bankstown-Lidcombe Hospital, will share responsibility for this tragedy.”
The lines that delivered the nitrous oxide will be removed while police are present as investigations continue, she said.
Mrs Skinner said NSW Health would stop using BOC Ltd and had required it to hand over work pending the result of an investigation
Only 0.6 per cent oxygen was coming out of its pipes.
“This would be considered negligible,” Chief Health Officer Kerry Chant said.
Dr Chant denied the engineer who had been stood down was being made a scapegoat.
“This is a catastrophic event for these families … the reality is I’ve outlined these facts as we know them,” she said.
Dr Chant said documentation suggested the line was tested upon installation but the “veracity” of those reports was now under question.
“Clearly who[ever] undertook that testing … is the matter for the investigation,” Dr Chant said.
The mothers of the babies had been in the operating theatre with their newborns shortly after giving birth when the gas was administered.
The error was discovered by paediatrician raised concerns about the unexpected death of the second baby.
The death has been referred to the coroner, and an independent root-cause analysis is also under way.
All eight operating theatres have now been checked and no other outlets were found to be faulty.
The outlet responsible has been fixed, but the theatre remains closed, Ms Skinner said in a statement.
On average 2,220 babies are born at the hospital each year.
Bankstown-Lidcombe Hospital has reviewed all records of babies delivered in this theatre since July 2015 and confirmed no other baby received gas from the affected outlet.
Every medical gas outlet in NSW is being audited, the minister said, and all future gas outlet upgrades would need independent verification.
Any future upgrade to medical gas outlets in a NSW public hospital will be required to undergo independent verification.
Professor Michael Nicholl, the clinical director of the Women, Children and Family Health at Northern Sydney Local Health District, is leading the continuing investigation.
His report is due by August 25.