‘Tragic errors’ behind NSW hospital gas mix-up that led to newborn death

The failed resuscitation of two babies at a Sydney hospital was caused by a tragic series of errors, according to the NSW Chief Health Officer’s report into a fatal gas bungle. The family of one of the babies has been left ‘distressed’ by the public release of the findings, claiming their recovery process is being ‘rushed’.

In July this year, Sonya Ghanem’s baby died after an emergency c-section at Bankstown-Lidcombe Hosital, when he was given nitrous gas instead of oxygen. A baby girl born at the hospital in June was left with serious health issues after also being resuscitated with the wrong gas at the hospital.

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Dr Kerry Chant’s report found that the incorrect installation of medical gas pipes in one of the hospital’s operating theatres, combined with flawed testing and commissioning of the pipes, led to the fatal gas error. Earlier this month a hospital engineer was stood down in relation to the bungle, and the general manager has been suspended.

“This was a catastrophic error and on behalf of NSW Health, I apologise unreservedly to both families,” Dr Chant said. “The purpose of my report was to investigate what went wrong and ensure that similar mistakes are not made in the future.”

The report also highlighted failings of both the South West Sydney Local Health District and BOC Ltd, which installed the medical gas piping. BOC says it has increased the level of testing in every new medical gas pipeline installation.

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The Ghanem family’s lawyer says his clients were not given enough time to consider the report before it was made public on Saturday.


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