BOC Limited cleared of wrongdoing in Bankstown-Lidcombe Hospital gas mix-up
A Sydney court has found a gas company did not breach its duty after two newborn babies were mistakenly given nitrous oxide instead of oxygen at Bankstown-Lidcombe Hospital.
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A gas company has been cleared over allegations it breached a health and safety duty after a fatal medical gas bungle at Bankstown-Lidcombe Hospital.
The 2016 incident resulted in the death of a baby boy after he was inadvertently given medical nitrous oxide instead of oxygen during neonatal resuscitation.
A month earlier, a female newborn had also been administered nitrous oxide from a port labelled oxygen in the same operating theatre.
She sustained serious injuries, including brain damage, epilepsy and vision impairment.
In 2015, the hospital engaged gas company BOC Limited to install, test and commission piped oxygen in the hospital’s operating theatres.
A report in 2016 by NSW Chief Medical Officer Kerry Chant found an existing pipe carrying nitrous oxide had been mislabelled oxygen prior to the 2015 works.
SafeWork NSW had sought to prosecute BOC Limited, alleging it had failed its duty under the Work Health and Safety Act.
The company pleaded not guilty.
It argued if testing procedures had been followed correctly by its contractor, as detailed in BOC test forms, the mistake would have been clear and risk could have been eliminated.
Judge Wendy Strathdee recently cleared the company of wrongdoing, saying it could not be held responsible for the behaviour of sub-contractor Christopher Turner, who was involved in installing the gas pipes in 2015 and whom she labelled a “disobedient worker”.
The judge found the evidence before the court indicated testing of the oxygen outlet in the operating theatre after installation “may not have been completed by Mr Turner at all.”
“It is impossible that if the testing regime had been properly performed, the cross-connection would not have been detected,” her judgment read.
“Whilst there is no evidence before me that Mr Turner did not do the required testing, or that he did not do it competently, on all the evidence I accept that nonetheless he falsified the testing documents.”
She also found NSW Health assistant engineer Paul Brightwell signed paperwork to say he had witnessed the testing despite not having observed any tests.
The court heard his signature on handover documents was required before the facilities could be used by hospital staff.
Mr Brightwell gave evidence he was handed documents by Mr Turner and was asked to sign the forms.
He is not being prosecuted by SafeWork NSW.
“The combination of the falsification of the documents by Mr Turner and Mr Brightwell had the most disastrous and tragic consequences,” Judge Strathdee said in her judgment.
“The babies were put at risk at the point in time the commissioning and handover was completed. They were put at risk because of the lies by Mr Turner and Mr Brightwell.”
A SafeWork NSW spokeswoman said the agency was “currently considering the judgment”.
Final orders will be made on June 1.
A spokeswoman for BOC Limited said the company continued to extend its deepest sympathies to the families involved.
“As the matter is still before the courts, BOC will not be making further comment.”
Mr Turner has pleaded guilty to failing to comply with a health and safety duty that exposed a person to risk of death, serious injury or illness.
His matter will return to court on May 8 for sentencing.