Two babies were accidentally administered nitrous oxide instead of oxygen during resuscitation at a Bankstown-Lidcombe hospital operating theatre in Sydney’s southwest. The nitrous oxide, also known as “laughing gas,” was incorrectly labelled as oxygen on the theatre’s gas supply wall units.
A boy, delivered by emergency caesarean section, died 57 minutes after he was born on July 13. A girl is in a critical condition with serious brain injuries, after being given nitrous oxide in late June. She is expected to suffer severe disabilities for the rest of her life.
The boy’s parents, Youssef and Sonya Ghanem, were not told for a week how their son died. It was almost a month before the girl’s parents were informed of what happened.
The gas lines were installed in mid-July 2015, 18 months after an oxygen bottle ran out during the resuscitation of a newborn baby in early 2014. BOC Limited, a major medical gas supplier and contractor to Australian hospitals, was engaged to install, test and commission the piped oxygen supplies.
A Root Cause Analysis (RCA) investigation began on June 23 into problems with the resuscitation of the girl, but it was not until a day after the death of the boy that a hospital paediatrician raised concerns about the gas lines. Eight days later, on July 21, BOC conducted a gas purity check and the theatre was closed.
BOC issued a statement claiming it was not involved in the original installation of the pipes, saying they were wrongly identified before its work at the hospital in 2015. The original pipes were fitted during the late 1990s.
The New South Wales (NSW) state government, which did not publicly release any information on the disaster until July 25, has responded by going into political damage control.
The government commissioned an interim inquiry headed by NSW chief health officer Dr Kerry Chant, suspended BOC from installing, commissioning or testing works at public hospitals, and stood down a Bankstown-Lidcombe hospital engineer.
NSW Health is also conducting a combined RCA investigation into the incidents, headed by Professor Michael Nicholl, the clinical director of Women, Children and Family Health at Northern Sydney Local Health District. Its report is scheduled for release on August 25.
State Health Minister Jillian Skinner described the death of the boy and injuries to the girl as a “devastating error” and said both families would be compensated.
Joe Kharma, an uncle of the boy, denounced Skinner’s response. Speaking to 2GB radio, he said: “I can’t understand how it’s just a ‘devastating error’ to the minister. You’re dealing with someone’s baby. Emotions are through the roof and all they can do is play the political game of covering up everything.”
Kharma said the parents were distraught. Their son lived for less than an hour, he said. “We’re speechless. All we want is justice … I can’t describe to you enough the feeling and the visuals we go through seeing a little white coffin go six feet into the ground. What makes it harder now is the fact that we know he was killed for nothing. They just kept pumping poison into him.”
Pre-empting the outcome of the RCA investigation, Skinner told the media that BOC, “who was responsible for the commissioning and installation of the line, along with a hospital engineer in the first instance, will be found to be involved.”
The RCA investigation and a future coronial inquest, she continued, would help identify whether hospital managers or staff contributed to the tragedy. “If so, they’ll be held to account,” she declared. In other words, Skinner and the government are looking for scapegoats to deflect attention from their own responsibility in creating the conditions that produced the tragedies.
Many questions remain unanswered. What testing was done on the gas lines before their commissioning? Why wasn’t the problem identified after the injury to the girl in June? Why did it take eight days, after a hospital paediatrician raised doubts about the wall outlets, before they were tested by BOC?
Mistakes were clearly made but they cannot be divorced from the conditions created in public hospitals by decades of under-funding and cost-cutting by federal and state governments, Liberal and Labor alike.
Doctors, midwives and other health workers, as well as hospital engineers and medical gas supply contractors, are constantly being told they must do more with fewer resources. This generates extreme pressure on staff to cut corners to get jobs completed, inevitably leading to errors.
The Australian Broadcasting Corporation recently reported that the South Western Sydney Local Health District, which covers the Bankstown-Lidcombe Hospital, was not meeting state targets for neo-natal care beds. Located in a rapidly growing working-class area, the facility should have had a minimum of 13 special care nursery beds by this year, but it only has 10.
A midwife who worked at the hospital for seven years said the maternity unit midwives were understaffed and “run off their feet.” She told the Bankstown-Canterbury Express: “I believe that a major problem is that when midwives are on maternity leave the hospital cannot employ anyone to replace them. The positions are kept on hold. And when they come back they usually come back only two days a week so the other three days cannot even be filled.”
According to the newspaper, the midwife “warned people not to jump to conclusions and blame maternity staff over the tragic mistake.”
The NSW Labor Party opposition has condemned the government investigation as “inadequate.” It called for the health minister to resign and declared it would move for a parliamentary upper house inquiry. This is so much hot air. Labor at federal and state levels, whether in government or opposition, has helped cut public health spending and slash jobs, while boosting private health industry profits.
Early this year, the Australian Medical Association’s 2015 annual report card for Australian hospitals warned that the health system faces a funding black hole in 2017 because of last year’s Liberal-National cost-cutting measures. The cutbacks, which Labor has endorsed, will slash federal funding by $1.7 billion over four years and an estimated $57 billion in the next decade.