Why does it take four years to put in place the obvious solution to a tragedy that killed one baby and seriously injured another ? In June 2016 the gas lines in the operating theatre at Bankstown Lidcombe hospital incorrectly delivered nitrous oxide when the signage indicated it was connected to oxygen.
This caused the death of one new born and permanent brain trauma to another. As a result, that child will never walk or talk. This incident caused an immediate investigation and it was discovered that the gas line installation was carried out by a person with no formal qualification for that job. He lied when he claimed that the necessary testing had been carried out on completion of the installation.
Ominously, it was discovered that medical gas line installation was not an occupation that required any form of lcensing and it has taken four years for that anomoly to be corrected. The legislation is now in place to ensure that medical gas is carried out by people qualified to do the job properly.
The aftermath of that tragedy should have been sufficient reason for immediate change. Safe Work NSW launched criminal proceedings against the man who did the installation. Banksrown Lidcombe hospital and the company who supplied the industrial gases to industry. The gas supplier was cleared by the court, Bankstown Lidcombe hospital entereed into an enforceable undertaking to change its management of medical gas installation, and the man who incorrectly installed the gas was fined $100,000 in the Downing Centre District court.
What this tragedy proved was that the safety aspect of job training and licensing in place to regulate industry does have anomolys. These can exist for years without incident, until the fates decree that someone dies as a result and the media spectrum is focussed on the shortfall.
We live in an age of innovation. We are constantly confronted with entirely new industries delivering services that can be extensions of previous technology and those extensions deliver new forms of danger. In those trades, people gravitate to new jobs and such extensions do not necessarilly require formal training, or the training requirement is far from adequate.
That this medical gas tragedy should have happened should be a wake up call for a long, hard look at what other industrial aspects have slipped through the safety net.
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