A deadly mistake at a Sydney hospital ended in tragedy after two babies were accidently administered nitrous oxide instead of oxygen.

An accident at Bankstown-Lidcombe Hospital has ended in tragedy leaving one baby dead and another with suspected brain damage. The babies were accidently administered nitrous oxide following an installation bungle, which led to an oxygen outlet being incorrectly connected to a nitrous oxide pipeline.

This type of accident although relatively rare is typical of systemic failure. Although undoubtedly designed with safety as a paramount concern, the medical gas delivery system in the hospital failed with catastrophic consequences. This deadly mistake has all the hallmarks of systemic or organisational failure.

Systemic or organisational accidents typically have multiple causes. They generally have a long history, involve many people and have widespread consequences, and the victims rarely initiate the events leading to the accident.

If any one cause had been mitigated, this accident might have been prevented. What went wrong? The final report, published on the 26th August 2016 provides some telling insight.

In January 2014 a baby in the birthing unit at Bankstown-Lidcombe Hospital required resuscitation. During resuscitation the oxygen bottle emptied. As a consequence, the baby was transferred to the special care nursery to receive ongoing treatment. Following this incident, the hospital decided to install piped oxygen to each of the birthing rooms to ensure an adequate oxygen supply. The engineering work to install the oxygen outlets in eight birthing rooms was conducted over two nights in July 2015.

The first accident in June 2016, involved a baby girl who suffered suspected brain damage. The second accident occurred three weeks later and resulted in the death of a baby boy. Both accidents happened in the same birthing room. As a result of a clinical review conducted by a paediatrician, the oxygen outlet in the room was tested. It was discovered to be dispensing nitrous oxide, not oxygen.

How was it possible that such a deadly mistake could be made?

Unfortunately, the oxygen outlet was connected to a nitrous oxide pipeline, mislabelled as oxygen. This mistake had been made twenty years earlier when the gas system was originally installed. Had that mislabelling been identified at the time, the accident might never have happened.

The engineering work to install the new oxygen outlets and its associated pipework was supposed to be undertaken in accordance with an Australian Standard, AS 2896-2011. This standard specifies the requirements to ensure safe construction, testing, certification, operation and maintenance of medical gas systems. This standard prescribes that while connecting any new pipework to existing pipework, only the pipeline to be cut in order to make the connection should be isolated and drained of pressure. Had this occurred the mislabelled nitrous oxide pipeline would have been identified because the pipe would have still been pressurised, instead of being unpressurised as expected. This was another missed opportunity.

The standard also prescribes a particular test to be performed when additions are made to existing pipework. This test is designed to ensure there has been no accidental cross-connection of the pipework. Had this test been performed the mistake would have been discovered. Finally, the standard requires a number of commissioning tests, including a gas identity test. The gas identity test had it been performed properly, should have revealed the presence nitrous oxide rather than oxygen.

The roots of this accident can be traced to a latent defect, which occurred some twenty years ago. At least four opportunities existed to detect and correct the defect, but each time the opportunity was lost. No doubt culpable parties will be identified and they may be prosecuted. But this type of accident will continue to occur. Perhaps it is time to adopt a different approach to system safety to avoid systemic failings.