Every medical gas outlet installed at an Illawarra health facility in the last five years is being checked after the death of a newborn boy who was mistakenly given the wrong gas at a Sydney hospital.
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The baby boy, named John, died at Bankstown-Lidcombe Hospital on July 13 after he was mistakenly treated with nitrous oxide, known as ‘’happy gas’’, instead of oxygen in the hospital's neonatal resuscitation unit.
Another baby boy, born at that hospital in June, remains in a critical condition after he also was mistakenly treated with nitrous oxide.
NSW Health Minister Jillian Skinner said the families were advised the oxygen outlet in one of the hospital’s theatres was incorrectly installed and certified by BOC Limited in July 2015.
Ms Skinner said all eight operating theatres at Bankstown-Lidcombe Hospital had now been checked and no other outlets were found to be faulty. The outlet responsible has been fixed, but the theatre remains closed.
In the wake of the incidents, the state’s 15 local health districts – including Illawarra Shoalhaven LHD – have urgently reviewed their protocols for ensuring medical gas outlets are correctly installed and verified.
An ISLHD spokeswoman said an independent contractor had commenced an audit of medical gas outlets installed in the region’s health facilities in the last five years to ensure the correct gas was being emitted.
All outlets that provide medical gases in ISLHD facilities are routinely inspected.
- ISLHD spokeswoman
‘’All outlets that provide medical gases in ISLHD facilities are routinely inspected to measure flow and pressure on an annual basis, ensuring compliance with Australian standards,’’ she said.
‘’The protocol also includes a visual inspection every six months. Upon installation of new medical gas outlets, the equipment is tested in the presence of an appropriate clinician, to certify correct gas connection.
‘’In addition, the supply of medical gas in all ISLHD operating theatres is checked before every list, including the circuit and ventilator. This tests the availability of each gas and the percentage of oxygen.
‘’Each gas has a unique pin configuration that ensures only oxygen supply, for example, can be connected to oxygen hoses.’’
NSW Health has contacted BOC Limited ‘’demanding urgent advice’’ on how the incorrect installation occurred. There’s also an investigation into whether the Sydney hospital staff followed protocols which may have detected the installation error last year.
