Distraught parents unable to face watching inquest into baby son’s death at Bankstown-Lidcombe Hospital
Tuesday should have been John Ghanem’s fifth birthday.
Instead, it marked the second day of the inquest for the newborn, who died due to a catastrophic mix-up in a Sydney hospital.
He died less than an hour after delivery, when he was ventilated with nitrous oxide from a hospital gas outlet marked “oxygen”.
“Already in a difficult week for John’s family this will be an even more difficult day for that reason,” counsel assisting the inquest, Donna Ward, acknowledged on Tuesday.
The court heard that John’s distraught parents were too affected by the first day of the inquest, which is largely being held remotely due to Sydney’s COVID-19 outbreak, to observe Tuesday’s proceedings.
Just how the laughing gas outlet in Bankstown-Lidcombe Hospital’s Operating Theatre 8 came to be incorrectly labelled is being probed in the NSW Coroners Court, with evidence from expert engineers.
The mistake not only cost John Ghanem his life, but caused severe brain damage in another newborn treated in the same operating theatre just weeks earlier.
Like John, Amelia Khan was ventilated with gas from the wall outlet. She was only revived when doctors treating her removed the resuscitation machine from the wall.
She now has lasting and serious disabilities.
The cross-connection mistake was discovered when a doctor who’d treated Amelia and heard about John’s death read about an incident in India where a child had been mistakenly given nitrous oxide from a port labelled “oxygen”.
Subsequent testing at the Sydney hospital revealed that no oxygen at all was coming from the oxygen port in the operating theatre.
Gas fitter Christopher Turner was last year fined $100,000 by the NSW District Court over John’s death, after pleading guilty to workplace safety breaches.
The inquest heard on Tuesday that he and other technicians engaged by contractor BOC Limited were working in a cramped and dark ceiling space in July 2015 when they connected existing gas pipes to new three-gang panels in the hospital’s surgical theatres.
They did not notice that the pipes had been incorrectly labelled decades before.
Unlike the usual set-up, the four pipes running parallel in the ceiling did not change direction equally, changing the order they were in.
That would have led to the “fundamental mistake” in labelling the pipes made 20 years earlier, said expert engineer Stuart Clifton.
Usually, depressuring each pipe as they worked on it but keeping the others live would help to alert technicians to a labelling error – as gas would be unexpectedly emitted when the pipe was cut.
That method was prescribed in the Australian Standard governing the work, to address the well-known risk of cross-connection.
However, it is not clear that the technicians used that method when connecting the pipes to the wall in the room where John died.
Adequate testing should have turned up the mistake, the court heard on Monday.
A hospital engineer signed off as a witness on a document which Turner signed to state he’d tested the pipes.
But the engineer was not actually present at the time, the District Court was told last year.
Testing standards have improved since baby John’s death, the expert engineers said on Tuesday.
The inquest continues.