I am profoundly sorry for the families of a newborn who died and another newborn who was severely affected after the wrong gas was dispensed through a neonatal resuscitation outlet at Bankstown-Lidcombe Hospital.

I deeply regret these families have suffered through such a devastating error. NSW Health will do all it can to support them.

Senior Bankstown-Lidcombe Hospital staff met with the families over the weekend for open disclosure of the facts surrounding the two births, which occurred in June and July this year.

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. The error was discovered last Thursday after a paediatrician raised concerns about the unexpected death of the newborn baby, which has been referred to the Coroner. Testing of the gas outlets found one oxygen outlet was emitting nitrous oxide instead of oxygen.

To reassure the public of the safety of Bankstown-Lidcombe Hospital and hospitals across NSW, I can confirm:

• Bankstown-Lidcombe Hospital has checked all eight operating theatres and found an installation fault in only one theatre, which remains closed.
• Bankstown-Lidcombe Hospital has reviewed all records of babies delivered in this theatre since July 2015 and confirmed no other baby received gas from the affected outlet.
• Every medical gas outlet installed in a NSW Health facility in the last five years is being checked to ensure the correct gas is being emitted.
• Secretary of NSW Health Elizabeth Koff has advised the state’s 15 Local Health Districts and two specialty networks have urgently reviewed their protocols for ensuring medical gas outlets are correctly installed and verified in compliance with the Australian standards.
• The legal General Counsel for NSW Health has written to BOC Limited, demanding urgent advice on how the error occurred and if there are any systemic issues in BOC processes which may impact other sites.
• South Western Sydney Local Health District is conducting a formal investigation to determine if Bankstown-Lidcombe Hospital staff followed protocols which may have detected the installation error last year.