By state political reporter Sarah Gerathy
An engineer at a Sydney hospital has been stood down over a fatal oxygen mix-up in the birthing unit and NSW Health has ceased using the company that installed the gas lines involved.
Last month, NSW Health confirmed three newborn babies were affected during incidents with the oxygen supply outlets at Bankstown-Lidcombe Hospital in Sydney’s south-west.
One infant died and another suffered suspected brain damaged when they were accidentally given nitrous oxide — also known as laughing gas — instead of oxygen from gas lines installed in the birthing suite.
The State Government has released an interim report into the mix-up, stating the engineer involved in commissioning the gas line had been stood down, pending the outcome of the investigation.
The interim report also confirmed NSW Health had stopped using the company BOC Ltd for installation, commissioning and testing works at all hospitals across the state until the investigation was completed.
Health Minister Jillian Skinner said it appeared both the hospital and the company that installed the gas were to blame.
NSW Opposition Leader Luke Foley has called on Ms Skinner to resign over the mix-up and the revelations of more than 100 cases of chemotherapy under-dosing in the state’s hospitals.
Coronial inquest to examine if other staff to blame
Ms Skinner said the full investigation and a coronial inquest into the baby boy’s death would help identify whether other hospital managers or staff contributed to the tragedy.
“If so, they’ll be held to account,” she said.
The gas lines had been installed after an oxygen bottle ran out in a birthing suite while a baby was being resuscitated in January 2014.
That baby survived the incident.
Ms Skinner said every medical gas outlet installed in NSW Health facilities over the past five years was now being checked to ensure the correct gas was being emitted.
She said a state-wide audit had also been extended to every medical gas outlet in NSW, irrespective of when it was installed.
The Minister said any future upgrade to medical gas outlets in NSW public hospitals would be required to undergo independent verification.
The State Opposition has declared it will move immediately for an Upper House inquiry into the incidents, saying the internal investigation the Minister ordered is inadequate.
Labels wrong before installation: BOC Ltd
In a statement, BOC said it was “extremely saddened by the tragic death” of the newborn and by the injury of another at the hospital.
The company said the incorrect labels on the gas pipelines were attached before their installation at the hospital.
“The original installation of pipes was not conducted by BOC.
“The July 2015 project documentation indicates that both a hospital representative and a BOC contractor were involved in the commissioning of the single oxygen outlet where the fault was found.”
The company said it would increase the level of testing in every new gas pipeline installation.
The full report is due to be completed by August 25.
This post originally appeared on ABC News.
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Top Comments
I have personally had dealings with BOC and I'm not exaggerating say this, they are one of the worst companies I have ever dealt with, in terms of incompetence. For a year they kept sending incorrect invoices (every month) for gas bottles we did not have, when we told them that we weren't going to pay for this they wanted us to prove that we didn't have the gas bottles. Well how do you prove something you don't have! This went on for over a year, every invoice was wrong. Also we had a head office but the gas had to go to another location, yet they could not deal with this, no matter how many times we told them they always put the location as head office, it seems as if their computer system would not allow the location to be different from the head office. The only reason the gas got delivered to the correct place was that the regular BOC delivery guy was aware that the address was a mistake, but sometimes if we delivered something else which was coming via courier (only the gas bottles were delivered by the BOC driver), the courier of course would deliver it incorrectly to the head office address, because BOC always had that wrong, and obviously the courier is just going off what is written as the delivery address.
I spent hours and hours and hours on the phone with BOC over the course of a year trying to address these problems, and every time there was to be a new order I would call them and tell them that they needed to deliver it to the right place this time, but they always delivered to the wrong place. We were being billed for double the amount of gas bottles we had. In the end someone there confided with me that it was their computer system that was the problem, so I don't think it was actually a staff issue, I think the computer system wouldn't allow them to input the right information. But on top of that every time I rang they were super smarmy nice to me, calling me by my first name in every single sentence (why do companies do that, it is super creepy) e.g. "Tina is there anything I can do for you today. Tina how many bottles do you want. Tina when do you want them delivered. Tina, tina tina...." did my head in! No normal person uses your name in every sentence, I could have put up with all that but it was just creepy that they were so inefficient but on top of that they act like they are my best friend (which I find quite inappropriate for a business relationship).
The only reason we persisted so long with them is because they appeared to have the monopoly, and even companies that seemed to be different (e.g. different name) was often controlled by BOC, so it took me a while to find another company, when I finally found the other company they were super efficient!
I know that everyone likes to have a whinge about companies from time to time, but BOC was really so bad that at one stage I thought of taking our complaint to Current Affair or similar.
I suspect that this engineer has become the convenient scapegoat for hospital management who ultimately is responsible for the safety and health of all patients and staff. An incubator is a life critical device and as such should always be independently tested and verified as 'fit for service' by an independent expert before being released for hospital use. This is a standard procedure in aerospace engineering and is one of the reason why flying an aeroplane is very safe today. In this case, the engineer performs the maintenance work and a second, independent expert, verify that the work has been performed correctly and the incubator is working according to its specifications, i.e. fit for service. It is the responsibility of the hospital management to make sure that such practices and procedures are in place when dealing with equipment that is life critical. If they have failed to such common engineering procedures and practices, then they're responsible, not the engineer/labourer.