One baby has died and the second is in a critical condition after the newborn infants were given nitrous oxide (NOx) instead of oxygen (O2) at a hospital in Sydney, Australia.

The wrong gas was dispensed through a neonatal resuscitation outlet at the Bankstown-Lidcombe Hospital in New South Wales (NSW), which was “incorrectly” installed and certified by BOC Limited in July 2015.

The fatal error was discovered on 21st July 2016 after a paediatrician raised concerns about the unexpected death of the newborn. Testing of the gas outlets then found an O2 outlet in the theatre was emitting NOx instead.

Since the discovery, NSW Government’s Minister for Health Jillian Skinner confirmed that the faulty neonatal unit at Bankstown-Lidcombe remains closed. She also stated that the other seven operating theatres in the hospital were inspected but were found to be functioning normally.

The death has been referred to the coroner.

In a statement, BOC Australia, a member of Tier One player The Linde Group, expressed, “BOC is extremely saddened of the tragic death of a newborn and the injury of another at Bankstown-Lidcombe Hospital over the past few weeks. We deeply regret that these families are suffering pain and sorrow.”

We cooperated fully with all investigations being undertaken by the NSW Government…It is extremely important to identify the exact cause of this tragedy

“As soon as BOC was notified of the situation we cooperated fully with all investigations being undertaken by the NSW Government – the Hospital, the NSW Coroner, and the Ministry of Health teams. It is extremely important to identify the exact cause of this tragedy.”

BOC underlined that it is conducting a full internal inquiry and has appointed a dedicated investigation team to clearly identify the root cause of the issue. The company also stated that it will work with the Ministry of Health throughout the investigations. 

South Western Sydney Local Health District is also conducting a formal investigation to determine if staff at Bankstown-Lidcombe Hospital followed protocols which could have detected the installation error last year.