The final report into a fatal oxygen mix-up at a western Sydney hospital has found “a series of tragic errors” led to one boy’s death and a baby girl’s serious injury.
The 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 this year.
A report by the New South Wales chief health officer, Dr Kerry Chant, released on Saturday, found the incorrect installation of medical gas pipes and flawed testing and commissioning of the pipes led to the two cases.
“This was a catastrophic error and, on behalf of NSW Health, I apologise unreservedly to both families,” Chant told reporters on Saturday.
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,” 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. Further interviews are taking place in relation to the investigation.
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.
The health minister, Jillian Skinner, did not appear before the media when the report was released.
Chant would not say why Skinner decided not to attend the press conference alongside her, nor would she comment on the minister’s handling of the fatal failure.
The boy’s family criticised Skinner for the timing of a final report into the deadly bungle.
“The family’s pain and suffering have been further exacerbated by the insistence of the minister for health in providing both the interim and final reports of the chief health officer to them and their legal representatives without sufficient time to consider them properly prior to their public release,” the family said through their lawyers.
“The minister has continually stated she is deeply sorry for the pain and suffering caused to the family. The timeliness of the release of these reports has done nothing to relieve that.”
The family said they were deeply distressed by the systemic failures at Bankstown-Lidcombe Hospital which led to their baby boy’s unnecessary death in July.
“If proper processes had been followed regarding the installation and testing of the gases, this tragedy would never have occurred,” they said.
“The family are hopeful that those responsible for these failures are brought to account and that procedures are put in place so that something like this will never happen to any family again.”
In a brief statement, 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.”
A spokeswoman from BOC said the company had already increased testing around every new medical gas pipeline it installs.
For each new medical gas pipeline a BOC representative who had not been part of the installation team was required to do the final tests and check of the system before it was used by the hospital.
The company also revealed the contractor involved in the fatal mix-up had not been provided any further work or projects since the investigation began.
The NSW opposition leader, Luke Foley, said it was a disgraceful “dereliction of duty” that no government ministers appeared for the release of the report.
“It’s utterly outrageous that when two babies are gassed nobody from the cabinet of NSW can be bothered to front up and speak with the public about it,” Foley told reporters outside the hospital.
He said Skinner should immediately stand down or be sacked, and an independent external investigation into the deadly bungle be launched.
A coroner will investigate the circumstances surrounding the baby boy’s death.