Tessa Davis. Lessons from Bankstown, Don't Forget the Bubbles, 2016. Available at:
A report has been released by the Chief Medical Officer, NSW, outlining the finding of the recent events in Bankstown-Lidcombe Hospital, where a baby died following a neonatal resuscitation. There are lessons to be learned for all of us from this tragic case. Here, we summarise the findings. The full report can be read here.
In June 2016, a neonate (Baby 1) was resuscitated in the operating theatres. The baby survived, but there was an unexpected poor outcome and so a RCA (Root Cause Analysis investigation) was initiated. A few weeks later, in July 2016, a second baby (Baby 2) was resuscitated in the same operating theatre. The baby tragically died. This case was referred to the coroner and consequently the police became involved.
The day after the death of Baby 2, a paediatrician requested testing of the gas outlets in this operating theatre. It was tested one week later and it was found that the oxygen outlet was emitting nitrous oxide.
When were the outlets initially installed?
18 months earlier, the hospital was using oxygen cylinders for neonatal resuscitation. On one occasion, a baby required resuscitation in the birthing suite using the oxygen cylinders, but the oxygen tank ran out. The baby had to be transferred to Special Care where they had more oxygen available. An RCA was instigated in this case, and consequently it was decided to install piped oxygen to the birthing suite and also to the neonatal resuscitation area in theatres.
This was installed in July 2015.
How many babies were resuscitated in this theatre?
Although the gas outlet was installed in July 2015, the outlet was not used in this theatre (one of 8 theatres) until June 2016 when Baby 1 was born. After checking records retrospectively, only Baby 1 and Baby 2 were resuscitated with gas in this theatre.
How was nitrous oxide connected to the oxygen outlet?
The report indicates two areas where mistakes occurred: the procedure for installing the gas; and the procedure for verifying the gas post-installation.
The gas was installed by an independent company. I am not an engineer, but my understanding of the process is as follows:
- when installing a new gas outlet, the engineer is required to isolate only the gas required
- the pipe for this gas is then drained of pressure
- when the pipe is then cut to make a new connection there will be no pressurised gas in that pipe
- if there is any pressure detected, then that indicates that the wrong gas is being attached to the new connection
In this case, rather than isolating just the oxygen gas, the engineer isolated all the gases, including nitrous oxide. Therefore, when cutting the pipe, there would be no indication that the wrong pipe had been cut.
Secondly, after installation the gas should have been verified as being oxygen. This verification should have been witnessed by a member of clinical staff who is experienced in delivering medical gases. The engineer has noted twice on the forms that the oxygen was tested and was 100% oxygen. This cannot have been the case as the actual reading would have been 0% oxygen. No clinical staff verified or witnessed this testing.
What are the report findings and recommendations?
The report identifies issues with the engineering process and also the governance within the hospital.
The RCA made a recommendation for submission to the Australian Resuscitation Council to review the existing neonatal resus algorithm. It recommends that a section be added about unexpected hypoxia which includes consideration of the gas outlets.
This is a tragic case and must be very stressful for all those involved. As clinicians who are frequently involved in neonatal resus, we have a process for reviewing equipment when faced with unexpected hypoxia during neonatal resuscitation. From now on, we should consider gas outlets as part of this trouble-shooting process and this may need to include a final step of disconnecting the baby from the piped gases and trialling on a self-inflating bag in room air.