Medical gases incident - final report

A report has been released on the tragic Bankstown-Lidcombe Hospital incident where two babies were resuscitated with nitrous oxide instead of oxygen.
There's been extensive coverage of this incident in which one neonate died and another was left with serious health issues due to the misinstallation of the wall gas outlet.

A final report has been prepared by the NSW chief health officer to update the NSW Health Minister in relation to these critical incidents that occurred at the hospital in June and July 2016.

A number of errors have been identified in the report. Importantly, the final safety check of the "oxygen" outlet for commissioning does not appear to have been done in compliance with Australian Standard 2896-2011; anaesthesia personnel were not engaged with the final testing process.

The standard requires that “A member of the health care facility experienced in administration of medical gases to patients, and such other persons as are required by the administration of the health care facility, shall be present and witness tests. Where non-respirable gases eg nitrous oxide and carbon dioxide, are piped, tests shall be performed by the anaesthetist-in-charge or a delegated anaesthetist.”

The report states that the hospital's department of anaesthesia was unaware of the installation works, and that the commissioning of the outlet was done without the presence of an anaesthetist.

More details can be found here.
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