Further to our previous article concerning the oxygen mix-up at Bankstown-Lidcombe hospital, the NSW government has now released the final report detailing how the error occurred.

Catastrophic injuries due to breach

One baby died and another suffered severe brain damage after they were given nitrous oxide instead of oxygen during resuscitation. The report confirmed what the wider public already knew, namely that a series of catastrophic errors led to these tragic outcomes.

The hospital installed oxygen outlets across all birthing units in July last year after one of its units experienced a shortage of oxygen whilst a newborn baby was being resuscitated. The hospital engaged the services of BOC Ltd to install, test and commission oxygen for the outlets of Operating Theatres 1-8. Whilst oxygen was installed into the outlets of the first seven operating theatres, nitrous oxide was mistakenly installed into the outlet of the eighth operating theatre.

The report identified a number of fundamental errors by both BOC Ltd and Bankstown Hospital. Firstly, BOC Ltd mislabelled the pipes which supplied oxygen and nitrous oxide which in turn resulted in the wrong gas being installed. Secondly, the tests conducted by BOC Ltd following installation mistakenly showed that oxygen, rather than nitrous oxide, was emerging from the outlet, highlighting a substantial fault in the testing process. Thirdly, none of the hospital’s clinical staff were involved in the testing process and the head of the Anaesthetics Department was unaware that the installation was taking place at that time. Each of the above amounted to a breach of acceptable protocol.

The fact that these incidents occurred almost a year after the outlets were installed demonstrates that they were preventable. Even if there were errors in the initial test results, subsequent testing periodically would have detected that the outlet in Operating Theatre 8 was installed with the wrong gas. The hospital, at the very least, should have tested the outlet after the first baby suffered brain damage in June.

In light of these incidents, the hospital’s general manager has been suspended. The hospital will also be monitored closely to ensure it adopts all of the recommendations suggested in the report. Whilst these measures are a step in the right direction, it will bring little comfort to the families affected.

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