Following the tragic news of the death of an infant in Australia last week after a faulty gas outlet in a neonatal unit was found to be emitting nitrous oxide (N2O) instead of oxygen (O2), BOC Limited has completed a Factual Investigation Report for Police in New South Wales (NSW).

The wrong gas was dispensed through a neonatal resuscitation outlet at the Bankstown-Lidcombe Hospital in the Australian state, which was initially thought to have been “incorrectly” installed and certified by BOC in July 2015, leaving one new-born dead and another in a critical condition.

However, during a recent inspection carried out by Police, hospital staff and BOC, it was found that both the medical O2 and medical N2O pipelines were incorrectly labelled prior to BOC’s work being undertaken at the hospital in July 2015, according to a statement from the company.

BOC also claimed that it did not carry out the original installation of the pipes.

BOC will be increasing the level of testing in every new medical gas pipeline installation above and beyond the requirements of the Australian Standard

Since the error was confirmed on 21st July, every medical gas outlet installed in a NSW Health facility in the last five years is being checked to ensure the correct gas is being emitted.

It is also understood that the hospital engineer involved in the original commissioning of the gas outlets in the theatre has been stood down.

In a statement, BOC said, “Regardless of the outcome of any investigations, BOC will be increasing the level of testing in every new medical gas pipeline installation above and beyond the requirements of the Australian Standard.”

Jillian Skinner, NSW Government’s Health Minister, clarified, “NSW Health has ceased using BOC for installation, commissioning and testing works at all NSW hospitals – including cancelling orders and requesting BOC hand over work already underway – pending the results of these investigations.”

She went on to say, “It is my strong belief that BOC Limited, which installed and certified the medical gas outlet, and Bankstown-Lidecombe Hospital, which was required under Australian standards to check it, will share responsibility for this tragedy.”