27 August 2016

​The NSW Chief Health Officer’s report into the Bankstown-Lidcombe Hospital medical gas incident has found a series of tragic errors led to the failed resuscitation of two babies.

One of the babies died and the other has been left with serious health issues.

Dr Kerry Chant’s report was provided to the families of the two babies on Friday morning, 26 August.

Each family also received the findings of an independently chaired root cause analysis (RCA) investigation that related to their babies.

The two babies were born at Bankstown-Lidcombe Hospital earlier this year – one in June and the other in July. Both babies needed resuscitation after birth.

Dr Chant’s report found the incorrect installation of medical gas pipes in one of Bankstown-Lidcombe Hospital’s operating theatres, followed by flawed testing and commissioning of the pipes, led to the two babies being resuscitated with nitrous oxide instead of oxygen.

The report also found broader clinical and corporate governance issues at the Hospital, specifically around the project planning and risk management of the commissioning of clinical infrastructure.

Australian Standard 2896-2011 sets out the procedures to be followed when certifying a medical gas installation. The report found that both South West Sydney Local Health District, of which Bankstown-Lidcombe Hospital forms a part, and BOC Ltd, the company that installed the medical gas piping, failed to comply with the standard.

The General Manager of the Hospital at the time the work was commissioned and an engineer involved in the commissioning process have been suspended. Further interviews are still to be conducted as the investigations continue.

“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.”

Since the mistaken gas configuration was uncovered at Bankstown-Lidcombe Hospital, medical gas outlets in all NSW health facilities have been tested to confirm the gas type, with no further issues of incorrect piping of gases being identified.

Dr Chant’s report made a number of recommendations, including that:

  • The Ministry of Health conduct a further review into the governance issues surrounding the commissioning of clinical infrastructure at Bankstown-Lidcombe Hospital
  • oversight of the current disciplinary investigation transfer from South Western Sydney Local Health District to the Ministry of Health
  • South Western Sydney Local Health District be put on a performance watch to ensure the RCA recommendations and any other recommendations arising from the current investigations are implemented.

The death of the baby who died in July was referred to the Coroner at the time. The Chief Health Officer’s report has also since been provided to the Coroner.

The report is available on the NSW Health website: http://www.health.nsw.gov.au/Hospitals/Pages/bankstown-lidcombe-incident.aspx​​​​

Page Updated: Saturday 27 August 2016