Sonya and Youssef Ghanem went to Sydney’s Bankstown-Lidcombe Hospital in July 2016 expecting to bring home a little brother for their three children.
Instead, their baby John died just under an hour after he was born.
Their grief was compounded when they learned their newborn had been ventilated not with oxygen, as the operating theatre’s gas outlet was labelled – but instead with nitrous oxide.
An inquest has begun into John’s death and the “shocking chain of events” at the hospital that led to it.
Sonya Ghanem arrived at the hospital on the morning of July 13, 2016 after her waters broke, counsel assisting the inquiry Donna Ward said in her opening address on Monday.
Her obstetrician decided she should have an emergency caesarean section because of a risk of infection and her baby’s slowing heartbeat.
Fatefully, she was wheeled into the hospital’s Operating Theatre 8. John was delivered at 11.54am.
He gave a weak cry but was not breathing properly. There was a loose loop of cord around his neck.
Doctors began desperate efforts to save his life, first rubbing him with a cloth, then applying a NeoPuff resuscitator.
When using room air did not work, they moved to ventilate him with what they believed was 100 per cent oxygen.
But instead, it was nitrous oxide coming out of the operating theatre’s gas panel.
John was declared dead at 12.51pm.
The death made no sense to the resuscitation team, who believed they’d done everything right.
Then a doctor’s hunch kicked in.
Paediatrician Dr Phillip Emder had treated another newborn, Amelia Khan, in the same operating theatre just weeks earlier.
He’d tried to resuscitate her with oxygen. Like baby John, she hadn’t responded as expected. She’d started to breathe on her own only after he’d connected the resuscitation device to another machine.
Amelia has been left with severe brain damage.
Emder raised his concerns with a nurse who’d helped to resuscitate Amelia.
She requested that the gas outlets be tested, expecting her concern to be actioned within four hours.
Instead it took nearly a week and a nudge from the nurse for Emder’s hunch to be confirmed.
There was no oxygen coming from the oxygen outlet – instead, it was nitrous oxide.
The inquest will examine the cause of baby John’s death, Ward said.
Other issues will be whether and how the gas pipelines were tested, and who installed them.
“One can’t truly understand what it must have been like for the Ghanem family as they both grieved the loss of their child and came to learn about the shocking chain of events at Bankstown-Lidcombe Hospital that led to his death,” Ward said.
“The fact that we cannot truly understand what that was like for them does not excuse us from trying to put ourselves in the position of the Ghanem family.”
The inquest follows workplace safety proceedings against gas fitter Christopher Turner and his employer.
Turner was fined $100,000 in 2020 after pleading guilty to breaching to the NSW Work Health and Safety Act.
His employer BOC Limited was found not guilty after a judge found it was deceived by Turner and the hospital’s assistant engineer.
A statewide investigation in 2016 revealed the hospital’s Operating Theatre 8 was the only place in NSW where medical gases were incorrectly piped.