One new born is dead and another is severely brain damaged after an incredible accident at Bankstown/Lidcombe hospital. It was discovered that one outlet in one of the hospitals eight birthing operating theatres was connected to the wrong gas. Instead of delivering Oxygen, it supplied Nitrous Oxide, commonly known as " Laughing gas " !
The supply of hospital gases comes from the industrial giant BOC limited and there are strict protocols in place in all medical establishments. All these procedures are now under review but it is worrying that this error remained in place for many days and that a great number of babies passed through that particular birthing centre successfully with the defect still in placer without suffering harm.
It seems that giving a new born oxygen is unusual. Most have a very healthy natural birth and it is simply not necessary to give oxygen, but where the birth is both difficult and lengthy a shot of oxygen can rejuvenate the baby. In this case, the oxygen probably stood unused as a standby during the many days it was incorrectly connected.
That Nitrous Oxide is also a standby gas. If labour is protracted and the mother is becoming distressed a little " laughing gas " can cause relaxation and dull the pain. Somehow, and against all protocol the gas line to the supply room managed to get connected to the wrong bottle - and nobody noticed.
This is the sort of medical disaster that strikes fear into all hospital administrations. You can be sure that when this news broke a special check was carried out on the gas connections and spigot labelling in birthing centres from Cape York to Tasmania. The fact that this is a cause of death that broke new ground - means gas protocols need to be tightened to ensure that it never happens again.
That is no solace for the victims. One baby is dead and another is in a critical condition with severe brain damage. It will result in a coroners enquiry and the protocols in place will be tightly examined to try and pin down exactly where this error occurred. It may be human error and there may be latitude in how things are labelled, but the entire system needs to be fine tuned because what has just happened is unacceptable.
The victim families must feel that fate was being cruel. It was just sheer good luck that many babies passed through that particular birthing centre procedure room with the incorrect gas connection before their turn, and many more after the first sign of damage was misdiagnosed. Both gases are colourless - odourless. Any reactions to gas are of an uncertain nature.
It is said that we live - and we learn. Just one of those unforseen hazards that an unkind fate can deliver - when we least expect it. What is important is that we close the door on repeat performances.
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