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You can find the current article at its original source at https://www.theguardian.com/australia-news/2016/aug/27/baby-death-report-finds-series-of-tragic-errors-caused-gas-mix-up-at-sydney-hospital
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| Baby death: report finds 'series of tragic errors' caused gas mix-up at Sydney hospital | Baby death: report finds 'series of tragic errors' caused gas mix-up at Sydney hospital |
| (about 2 hours later) | |
| 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 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. | 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. | 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. | “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. | |
| 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.” |