John Ghanem inquest: baby lived just one hour due to gas bungle

A family was expecting the birth of their fourth child. Instead they were in mourning after an unforeseen error cost their child his life.

A deadly gas bungle killed a baby after inadequate, or possibly even non-existent, testing of new gas equipment installed at a western Sydney hospital, an inquest has heard.

Only an hour after he was born, baby boy John Ghanem was dead despite the desperate attempts of doctors to get him breathing using what they believed was a steady supply of oxygen.

Tragically, the gas being pumped through little John’s body was nitrous oxide – commonly known as laughing gas – due to an installation error that went undetected for more than a year.

The bungle only came to light after a doctor saw similarities between the incident and a story he had read about the death of a boy in India due to a mix up between nitrous oxide and oxygen gas lines.

Sonya Ghanem and her husband Youssef, whose newborn son John died after being administered nitrous oxide.

How the heartbreaking incident came to unfold in operating theatre eight at Bankstown-Lidcombe Hospital on July 13, 2016 is being explored in an inquest held at the Lidcombe Coroners Court.

On Monday, the court heard of the “shocking chain of events” that turned what should have been a day for celebration for the Ghanem family into one of mourning.

Counsel Assisting the Coroner Donna Ward told the court testing of a new gas panel installed in theatre eight in July 2015 was not done “adequately or at all”.

Ms Ward said subcontractors who installed the panel had failed to pick up a cross-connection issue in the roof space where the nitrous oxide and oxygen lines were mislabeled.

The contractor held responsible for the mix up, Christopher Turner, would later plead guilty to failing to comply with his work health and safety duty and was fined $100,000.

Ms Ward said the inquest would focus on “what would any of us expect to see happen after the circumstances of John’s death … to try and minimise the chance of it ever happening again”.

Amelia Khan was one of two babies given nitrous oxide after it was mistaken for oxygen when she was born at Bankstown-Lidcombe Hospital in 2016.

Just weeks before John’s death, baby girl Amelia Khan was left with permanent brain damage after she was also accidentally administered nitrous oxide after being born in the same operating theatre.

The fourth child of Youssef and Sonya Ghanem, John was born about midday on July 13 via caesarean after doctors detected bacteria linked to neonatal sepsis in his mother’s system.

After birth he was placed in a neonatal resuscitation bay as doctors noticed a loose part of his umbilical cord was wrapped around his neck and he wasn’t breathing properly.

“John gave a weak cry but no sustained respiratory effort,” Ms Ward said.

The incidents left staff at Bankstown-Lidcombe Hospital perplexed.

His heart rate dropping, doctors fitted a puffer mask to the boy to pump room air into his lungs but he did not respond well, so they hooked the mask up to the gas line labelled as oxygen.

They were perplexed when he did not respond as expected and he was pronounced dead after several attempts to improve his condition, including CPR, life support and an adrenaline shot.

“John had lived for just under one hour,” Ms Ward said.

“Ultimately Sonya and Youssef got to spend time with their baby boy. But this was after John had died.”

Ms Ward said the boy’s passing also deeply affected those who treated him, owing to the fact the death “made no sense” to them.

The inquest continues.