Bankstown-Lidcombe Hospital

Medical Gases Incident:

Final Report

Prepared by the Chief Health Officer

26 August 2016
 Chief Health Officer Final Report

1. Purpose
This Report has been prepared by the Chief Health Officer to update the NSW Minister
for Health in relation to critical incidents that occurred at Bankstown-Lidcombe
Hospital in June and July 2016: dispensing incorrect gas to two neonates through a
neonatal resuscitaire in Operating Theatre 8. Specifically, this Report has been
informed by:

• Expert Report: Theatre 8 Medical Gas Cross Connection Bankstown-Lidcombe

Hospital (17 August 2016) - prepared by Stuart Clifton, engaged by NSW Health
as an expert engineer
• Root Cause Analysis (RCA) investigation report
• Correspondence from BOC Limited (Ltd.)
• Status advice on the disciplinary proceedings

2. Introduction
Bankstown‐Lidcombe Hospital (part of South Western Sydney Local Health District
[SWSLHD]) is a principal referral group A1 hospital with tertiary affiliations to the
University of NSW, University of Sydney and University of Western Sydney. It provides a
wide range of general medical and surgical services and some sub‐specialty services to
communities in Bankstown-Canterbury Local Government Area (LGA). Clinical services
in the Hospital are mainly at role delineation level 5.

It provides clinical services in: emergency medicine; cardiology; surgical sub‐specialties

including general, ENT, colorectal, peripheral neurosurgery, ophthalmology,
orthopaedics, plastics, upper gastrointestinal pancreatic and biliary, vascular, breast
and urology; medical sub‐specialties including general medicine, endocrinology,
gastroenterology, infectious diseases, neurology, neurophysiology, renal medicine,
respiratory and rheumatology; cancer therapy including medical and surgical oncology,
chemotherapy and haematology; intensive care unit/high dependency unit; maternity,
gynaecology, special care nursery and paediatrics; mental health; drug health;
rehabilitation and aged care; and imaging.

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In relation to maternity services, Bankstown-Lidcombe Hospital has 10 neonatal cribs

in the special care nursery and six birthing unit suites, which are supported by eight
operating theatres.

On average 2,220 babies are born each year at Bankstown-Lidcombe Hospital.

3. Background / Summary of Events

In January 2014, a baby who required resuscitation was delivered in the birthing unit at
Bankstown-Lidcombe Hospital. During the resuscitation the oxygen cylinder emptied
and staff transferred the baby to the special care nursery across the corridor to ensure
ongoing oxygen supply for the resuscitation.

Following a Root Cause Analysis (RCA) investigation into the circumstances

surrounding the care provided, the Hospital installed piped oxygen outlets in the
birthing unit that provided a constant oxygen supply for the resuscitaires in the birthing
unit.

The decision was subsequently made to install piped oxygen to the neonatal
resuscitaires in the operating theatres. The approval for work to proceed was given by
the General Manager on 10 June 2015.

Bankstown-Lidcombe Hospital engaged BOC Ltd. to install, test and commission piped
oxygen for the resuscitaires in Operating Theatres 1-8. Fire officer documentation
obtained by the disciplinary investigation team indicates that the BOC Ltd. contractor
attended to the work over two nights, 14 and 15 July, and the work was completed on
16 July 2015.

While Operating Theatre 8 continued to be used, there was no cause for the newly
installed gas outlet to be used until late June 2016 when Baby 1 was born and required
resuscitation following delivery. The baby survived, with an unexpected poor outcome.
An investigation through the RCA process was commenced to understand the reasons
for the unexpected poor outcome.

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On 13 July 2016, Baby 2 was born in the same operating theatre. Baby 2 required
resuscitation and died. This incident was referred for a mandatory patient RCA.

The unexpected death of Baby 2 was notified to the Coroner on 13 July 2016, with the
senior paediatrician advising Baby 2’s family that this was required under the law. Later
that day, in response to the referral, police from Bankstown Police Station attended the
Hospital to conduct inquiries.

Another paediatrician involved in the clinical review of the cases requested testing of
the gas outlets in Operating Theatre 8 on 14 July 2016 to understand whether this could
have in any way contributed to the unexpected outcome. A work order for this testing
was put in place. The gas outlet was not required to be used from 14 July 2016.

The oxygen outlet was tested by BOC Ltd. and subsequently by Hoslab on 21 July 2016
and was found to be emitting nitrous oxide instead of oxygen. Operating Theatre 8 was
closed from this date until it was rectified on Thursday 18 August 2016 in a process that
was compliant with the relevant Australian Standard.

On 21 July, in order to ensure that no other babies had been exposed to nitrous oxide,
Surginet (a theatre booking system) was interrogated and cross checked against the
birth register and medical records. It indicated 36 patients had given birth in Operating
Theatre 8. A full review of the clinical records was completed on the morning of 22 July
2016. This showed the neonatal resuscitaire in Operating Theatre 8 was used on two
neonates (Baby 1 and Baby 2).

SWSLHD arranged for the testing of all gas outlets in operating theatres and birthing
units in all hospitals across SWSLHD, commencing on 21 July and completed on 26 July.
This testing was subsequently extended to all gas outlets across SWSLHD.

A range of investigations were commenced to identify the cause of this catastrophic

error and identify lessons to prevent a recurrence, and immediate action was taken to
confirm this was an isolated, albeit catastrophic, error (refer to Section 6: NSW Health
system response).

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The investigations instigated by NSW Health include:

1. Independently chaired Root Cause Analysis (RCA) investigation

A decision to commence an RCA in relation to Baby 1 was made on 23 June 2016. Baby
2’s death was referred to a mandatory RCA on 13 July 2016. However, due to the critical
information in relation to the error with the gas outlet being discovered, a new RCA
covering the cases of Babies 1 and 2 was initiated on Monday 25 July.

The RCA team was led by Professor Michael Nicholl, Clinical Director, Division of
Women’s, Children’s and Family Health, Northern Sydney Local Health District.
Membership of the RCA team is listed at Appendix H.

The RCA investigation included a review of the antenatal and intra-partum care,
resuscitation of both neonates and the processes for medical gas piping installation and
commissioning that occurred in the operating theatres in July 2015.

The parents of Baby 1 and Baby 2 will be provided with the aspects of the RCA that
pertain to them and their baby as well as a common section covering the incorrect
installation and commissioning of the medical gases to the neonatal resuscitaire in
Operating Theatre 8.

2. Independent expert engineer’s report

The ‘Expert Report: Theatre 8 Medical Gas Cross Connection Bankstown-Lidcombe
Hospital (17 August 2016)’ was prepared by Stuart Clifton, who was engaged by
NSW Health as an expert engineer.

3. Disciplinary investigation
Following the suspension of an engineer involved in signing the commissioning
test form as a witness, a formal disciplinary process was commenced. This has
involved initial interviews with those directly involved in the events surrounding
the installation and commissioning to identify individual accountability. Fourteen
staff have been interviewed and having regard to the information obtained to date,
a further 13 interviews are planned, including a number of senior managers.
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Lawyers for the engineer advised their client would not be participating in the
investigation given the pending coronial inquiry.

4. Existing relevant statewide policies

The following relevant statewide policy directives were in force at the time of the
installation:

• NSW Health Process of Facility Planning (POFP) Guidelines for Projects Valued
less than $10M (2010), disseminated via Policy Directive 2010_035
([Link] and

• NSW Health Engineering Services and Sustainable Development Guidelines

Technical Series TS11 (Version 2.0 December 2007), disseminated via Guideline
2008_002
([Link]

The NSW Process of Facility Planning (POFP) provides a robust framework for planning
and procuring capital infrastructure across the NSW public health system. The
Engineering Services and Sustainable Development Guidelines are intended as a
handbook to be used during the briefing and design process and these require
compliance with Australian Standard 2896-2011 in relation to the installation of
medical gases.

5. Findings of the Root Cause Analysis and expert engineer

The RCA and the independent expert engineer’s report identify the flawed installation
and subsequent flawed testing and commissioning process as the cause of the
administration of nitrous oxide instead of oxygen to Baby 1 and Baby 2.

The reports also raise issues relating to project planning, governance and risk
assessment evident at Bankstown-Lidcombe Hospital. The RCA investigation report
notes it was unable to locate a number of relevant documents as described under the
Local Health District’s “Contract Management Procedure” (PCP2015_009) and “Minor

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Capital Works Approval” (PD2014_A01.19). A “permit to work” form and a risk

assessment and safe work method statement could not be located.

The RCA identified several gaps in Bankstown-Lidcombe Hospital’s and the District’s
engineering governance and management processes, as well as a need to clarify and
strengthen the relationship between the Local Health District and the Hospital’s
engineering services.

An email from the Nurse Unit Manager of perioperative services at Bankstown-

Lidcombe Hospital dated 14 July 2015 indicates that the work was planned to be
undertaken over two nights (14 and 15 July 2015) with four operating theatres being
completed each night. The ‘Engineering Department Permit for Hot Work and Fire
Isolations’ form, located by the disciplinary investigation, indicates the BOC Ltd.
contractor was issued with permits for two nights – 14-15 and 15-16 July 2015. The
BOC Ltd. test certificate form T5 indicates the testing was undertaken on 15 July 2015
(Appendix A).

The relevant Australian Standard that covers this work is AS2896: Medical gas systems -
installations of non-flammable medical gas pipeline systems. This Standard has been
revised and updated a number of times in the past 30 years with the latest release in
2011. The expert engineer notes “this Standard is used in all medical gas installations in
Australia”.

The report continues: “The Standard sets out the requirements for the safety aspects,
construction, testing and certification, operation and maintenance of non-flammable
medical gas pipeline systems used for patient care, therapeutic, diagnostic and for
operating surgical tools. Non-flammable medical gas pipeline systems include suction
pipeline systems.”

The expert engineer notes that two sections of the Standard are particularly relevant:
clause 4.13 and section 5.

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Clause 4.13: Connection to existing systems - “Connections to existing systems shall be

undertaken in only one gas system at a time to minimise the risk of cross-connection.”

This prescribes that only the gas to be cut in is isolated and the local pipe drained of
pressure. When the pipe is then cut into to make the new connection there should be no
pressurised gas. If pressurised gas is present the installer knows there is an issue with
the gas type.

The expert engineer concludes: “It is apparent that all gases including nitrous oxide
were isolated during installation. Therefore when the nitrous oxide pipe was cut into
there would have been no indication that the wrong pipe was cut.”

The original pipework in the Bankstown-Lidcombe Hospital operating theatres was

installed as part of the original build of the facility some 20 years ago by Hoslab. The
expert engineer observed that the existing ceiling pipework supplying oxygen and
nitrous oxide to the medical gas panel in the anaesthetic bay had been mislabelled. The
pipework carrying nitrous oxide had been labelled oxygen at the end closest to the
Operating Theatre 8 anaesthetic bay while at the other end (approximately 4 metres
away) it was correctly labelled nitrous oxide. An identical situation happened with the
oxygen pipework with one end incorrectly labelled nitrous oxide and the other end
correctly labelled oxygen.

However, if correct procedures were followed at the time of installation in July 2015,
when the oxygen supply was turned off at the main medical control panel, and the
pressure released, when attempting to cut into the pipeline (wrongly labelled oxygen),
the cross connection would have been identified as the pipe being cut (which was
actually nitrous oxide) and would have been pressurized at 410KPA.

The expert engineer notes: “I am of the opinion that the incorrect affixing of 2 pipe
labels in the original install would have resulted in redundant work by BOC but due to
the other checks at the time of installation and commissioning that BOC were required
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to undertake, the mislabelling of the pipework would have had no bearing on the cross
connection as relying on the pipe label only would have caused them to cut the wrong
pipe.”

Section 5 Testing and Certification - the expert engineer indicates this section of the
Australian Standard sets out the procedures for certifying a medical gas installation
that, if followed, would make it impossible for the system not to operate safely.

Extract from AS 2896-2011

5.7 Certification of systems

5.7.1 Operational test

Prior to the commissioning of a medical gas system, testing by a designated person shall be
performed to determine that the concentration of the medical gas is correct and that there
is no contamination. A member of the health care facility experienced in the
administration of medical gases to patients and such other persons as are required by the
administration of the health care facility, shall be present and witness the tests. Where
non-respirable medical gases, e.g. nitrous oxide and carbon dioxide are piped, tests shall be
performed by the anaesthetist-in-charge or a delegated anaesthetist. If any gas is supplied
at more than one pressure, testing shall be performed with only one pipeline pressurized
on each occasion.

The process for testing for gas purity (see Appendix A: BOC Test Certificate Form T5,
part 12) is the ultimate test to ensure that the right gas comes out of the right outlets.
The results recorded on the Medical Gas Outlet Test Form (Appendix B) are incorrect as
confirmed by Hoslab on 21 July 2016 (Appendix C). The expert engineer notes the
recorded value of 100% for the oxygen outlet would not be possible when using an
oxygen analyser as no oxygen was present, hence a value close to 0% should have been
recorded. He also notes that looking at the Medical Gas Outlet Test Form (Appendix B)

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for Operating Theatre 8 it appears that the outlet purity was measured twice with 100%
recorded in both instances.

Investigations to date indicate that no clinical staff were involved in the witness testing.
Based on the information available to me, the Head of the Anaesthetics Department at
Bankstown-Lidcombe Hospital was unaware of the installation work being undertaken
at that time.

6. NSW Health system response

On 21 July 2016, the Ministry of Health was notified of the incident and convened a
teleconference to establish the key facts and support the statewide and local response
to the incident.

On the morning of 22 July, all Local Health Districts and Specialty Health Networks were
instructed to provide advice in relation to the following:

1. What is the process to verify that the gases coming from medical gas outlets on
the wall are correct at commissioning and if there are any changes to the gas
supply?
2. Are clinicians involved in this process and how?
3. How frequently are gas outlets checked?

At 2pm on 22 July the Clinical Excellence Commission (CEC) held a teleconference with
Local Health Districts and Specialty Health Networks to confirm the nature of the
request, timelines for response, and address any issues requiring clarification. Appendix
E identifies the responses to these questions. Later on 22 July, an assurance was sought
from Local Health Districts and Specialty Health Networks that the identified processes
were adhered to.

Responses from Local Health Districts and Speciality Health Networks indicated the
outlet commissioning processes they have in place complied with Australian Standard
2896-2011 with the exception of Far West Local Health District. Systems are now in
place in Far West Local Health District to ensure future witness testing for

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commissioning of new outlets includes a member of the health care facility with
experience in the administration of medical gases to patients or anaesthetist where
required.

Issues associated with incorrect piping of gases (such as nitrous oxide being emitted
instead of oxygen) have clinically significant impacts. The risk assessment identified this
to be a very low risk of occurrence but potentially having catastrophic consequences.
This particular error can occur where nitrous oxide and oxygen are both piped, such as
in operating theatres, and occurs when there is an error in both the installation and the
subsequent testing process. The CEC reviewed the Incident Information Management
System to search for any incidents of this nature and found none.

On Monday 25 July 2016, Local Health Districts and Specialty Health Networks were
instructed to undertake testing (i.e. analysis of gas type) of any recently commissioned
units or where pipe work had been undertaken (e.g. operating theatres, critical care,
emergency departments and maternity) in the last 24 months, particularly focusing on
areas where the gas outlets may not have been used or used infrequently. This advice
was requested to be provided within 24 hours.

Late on Monday 25 July, the scope was extended to all new works or refurbishments
within the last five years and this was followed up with additional correspondence on
Tuesday 26 July. Appendix F provides a report in relation to this work.

On 29 July, in order to provide further assurance, the Minister directed testing of all gas
outlets in NSW Health facilities be undertaken. The Health Secretary wrote to all Chief
Executives of Local Health Districts and Specialty Health Networks to:

1. Test, using a gas analyser, each medical gas outlet installed within any facility (new
build or upgrade) within the last five years to confirm the gas type and
concentration. The testing was to include air and oxygen medical gas outlets
whether co-located with other gases or not. Advice confirming that the testing had
occurred and the outcome of that testing was to be provided to the Chief Health
Officer by close of business Monday 1 August 2016.

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2. Test, using a gas analyser, all other medical gas outlets in NSW Health facilities to
confirm the gas type and concentration. The testing was to include air and oxygen
medical gas outlets whether co-located with other gases or not.
Advice confirming the testing had occurred and the outcome of that testing was to
be provided to the Chief Health Officer by close of business Monday 15 August 2016.

Appendix G confirms that testing of all medical gas outlets in use is complete and no
issues of incorrect piping of gases were identified.

Health Infrastructure confirmed that for capital works in NSW Health facilities managed
by Health Infrastructure, a three-step process for commissioning is undertaken. Step 1,
the subcontractor to the principal contractor confirms the installation is compliant with
the design. Step 2, the principal contractor will confirm to NSW Health representatives
that the system is ready to be tested and Step 3, the certification process occurs in
accordance with Australian Standard 2896-2011.

NSW Health has drawn on advice from a CEC expert group to advise on whether
additional statewide policy or protocols on medical gas installation should be
considered.

7. Conclusion
Both babies required resuscitation following their birth and the administration of
nitrous oxide instead of oxygen prevented effective resuscitations. The death of Baby 2
has been referred to the Coroner who will determine the cause and manner of death.

The incorrect installation of the pipes and subsequent flawed testing and
commissioning process, which should have detected the installation error, led to the
babies being resuscitated with nitrous oxide instead of oxygen. The processes followed
did not comply with Australian Standard 2896-2011. Both BOC Ltd. and South Western

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Sydney Local Health District staff have responsibilities in this regard which, in my view,
were not met.

Both the RCA and expert engineer’s report raise broader issues about the project
planning and risk management of the commissioning of clinical infrastructure at
Bankstown-Lidcombe Hospital and the governance, both clinical and corporate, thereof.
Robust governance processes for the commissioning of clinical infrastructure provide
an essential safeguard against the risks arising from individual error.

8. Recommendations
1. In light of the issues identified by the RCA and independent expert engineer’s
report, a review of senior management’s role in relation to the broader
governance (both clinical and corporate) of the commissioning of clinical
infrastructure at Bankstown-Lidcombe Hospital is to be undertaken by the
Ministry of Health.
2. Oversight of the current disciplinary investigation is to transfer from the Local
Health District to the Ministry of Health.
3. The Ministry of Health is to promulgate a standard set of requirements for the
engagement of contractors which includes the requirement for contractors to
have a separation of the installer and the tester.
4. The Ministry of Health is to write to Australian Standards suggesting it consider
whether Australian Standard 2896-2011 requires clarification in relation to the
situations in which the presence of an anaesthetist is required and consider an
additional requirement to separate the installer and the tester.
5. The Ministry of Health accepts the RCA recommendation in regard to a
submission to the Australian Resuscitation Council requesting review of the
existing algorithm and flowchart to include a process during unexpected hypoxia
for checking and changing the gas supply and circuits, including a final step of
isolation of the neonate from the circuit and gas supply and changing to a self-
inflating bag using room air only.

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6. South Western Sydney Local Health District is to be put on performance watch,

under the NSW Health performance framework, and monitored for the purpose
of ensuring the RCA recommendations and any other recommendations arising
are implemented.

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Appendix A – BOC Ltd. test certificate form T5

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Appendix B – BOC Ltd. medical gas outlet test form

NOTE: Findings for

Operating Theatre 8
not consistent with
Hoslab test results from
21 July 2016

Signature of BOC Signature of hospital

Ltd. representative engineer

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Appendix C – Service report sheet from Hoslab regarding Operating

Theatre 8 testing

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Appendix D – Timeline of events relating to the medical gas incident

Date Event
Late June 2016 Attempted resuscitation of Baby 1 using wall-outlet labelled “oxygen” in
Operating Theatre 8. First time outlet has been used since installation.
Baby transferred to high-level facility for care.
23 June 2016 Decision for a RCA investigation into the circumstances around Baby 1’s
birth and care.
13 July 2016 Attempted resuscitation of Baby 2 using wall-outlet labelled oxygen in
Operating Theatre 8. Resuscitation attempt unsuccessful.
Death reported to the Coroner, family informed by senior paediatrician of
the referral.
NSW Police attended Bankstown-Lidcombe Hospital after the referral to
the Coroner.
14 July 2016 Paediatrician requests check of gas outlet used for neonatal resuscitations;
engineering work order issued as paediatrician was interested in exploring
any possible contribution to the unexpected poor outcome. The gas outlet
in Operating Theatre 8 neonatal resuscitaire was not required to be used in
the period until Operating Theatre 8 was closed.
21 July 2016 Gas outlet in Operating Theatre 8 neonatal resuscitaire tested by both BOC
Ltd. and Hoslab and found to be emitting nitrous oxide instead of oxygen.
Operating Theatre 8 was closed.
Testing of all gas outlets in operating theatres and birthing units across
South Western Sydney Local Health District commenced (concluded 26 July
2016).
Ministry of Health and Clinical Excellence Commission notified.
Process for Open Disclosure commenced.
22 July 2016 Contact made with the families to notify them of the facts surrounding the
two births through an open disclosure process.
Open disclosure occurred with family of Baby 1 at 6pm. Family of Baby 1
requested privacy.
An appointment was made with Family of Baby 2 for the following day.
General Counsel NSW Health writes to BOC Limited seeking urgent advice.
Chief Executive SWSLHD writes to the State Coroner informing him of
information relating to gas outlets not known when the initial report is
made.
23 July 2016 Family of Baby 2 open disclosure meeting held at 3pm.
25 July 2016 BOC Ltd. advises NSW Health that it is conducting an investigation.
Visit to site by NSW Police (on behalf of the State Coroner).
26 July 2016 Media conference conducted by Minister for Health and Health Secretary.
Follow up site visit by Police.
27 July 2016 Site inspection by BOC and LHD.
Follow up visit by Police and their expert engineer.
28 July 2016 Further site visit by BOC, LHD and Police.
29 July 2016 First meeting of independently chaired RCA investigation team.

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Appendix E – Response to questions regarding gas outlet

commissioning processes (excluding SWS LHD)
LHD Verification Process Frequency of check (pressure/flow)
St Vincent’s Verified according to the AS2896-2011. Outlets checked as per AS2896-2011

SCHN Verified according to the AS2896-2011. Outlets checked as per AS2896-2011

Central Coast Verified according to the AS2896-2011. Outlets checked as per AS2896-2011

Far West Has been verified by two independent Outlets checked six monthly, i.e. more
gas technicians and a LHD technician frequently than required by AS2896-2011
with specific medical gas training.
Process in place to ensure future
verification complies with AS2896-2011,
through the inclusion of a clinician.

Hunter New Verified according to the AS2896-2011. Outlets checked as per AS2896-2011
England
Illawarra Verified according to the AS2896-2011. Outlets checked as per AS2896-2011
Shoalhaven
Mid North Verified according to the AS2896-2011. Outlets checked as per AS2896-2011
Coast
Murrumbidgee Verified according to the AS2896-2011. Outlets checked six monthly, i.e. more
frequently than required by AS2896-2011

Nepean Blue Verified according to the AS2896-2011. Outlets checked as per AS2896-2011
Mountains
Northern NSW Verified according to the AS2896-2011. Outlets checked as per AS2896-2011

Northern Verified according to the AS2896-2011. Outlets checked as per AS2896-2011

Sydney
SES Verified according to the AS2896-2011. Outlets checked at least annually (some as
often as monthly), exceeding the
requirements of AS2896-2011

Southern NSW Verified according to the AS2896-2011. Outlets checked as per AS2896-2011

Sydney Verified according to the AS2896-2011. Outlets checked as per AS2896-2011

Western NSW Verified according to the AS2896-2011. Outlets checked as per AS2896-2011

Western Verified according to the AS2896-2011. Outlets checked as per AS2896-2011

Sydney

Justice Health Verified according to the AS2896-2011. New outlet will be checked as per AS2896-
& Forensic [One outlet is not in use and is being 2011
Mental Health considered for decommissioning.]

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Appendix F – Checking of newly-commissioned gas outlets for gas type

(within past 5 years)
LHD Sites where re-testing complete Sites remaining Expected completion
to be re-tested date/Status
SCHN Sydney Children’s Hospital, Randwick Nil Complete
The Children’s Hospital at Westmead No issues identified
Southern NSW South East Regional Hospital (Bega) Nil Complete
Yass Hospital No issues identified
Moruya Hospital
Goulburn Hospital
Batemans Bay
CCLHD Gosford Hospital Nil Complete
Wyong Hospital No issues identified
Woy Woy Hospital
Long Jetty Hospital
SLHD Canterbury Hospital Nil Complete
Royal Prince Alfred Hospital No issues identified
Concord Hospital
NBMLHD Blue Mountains Day Procedure Centre Nil Complete
Nepean Hospital No issues identified
WSLHD Auburn Hospital Nil Complete
Westmead Hospital No issues identified
Blacktown Hospital
Mt Druitt Hospital
ISLHD Shoalhaven Hospital Nil Complete
Shellharbour Hospital No issues identified
Wollongong Hospital
Bulli Hospital
HNELHD John Hunter Hospital Nil Complete
Tamworth Hospital No issues identified
Narrabri Hospital
Scott Memorial Hospital - Scone
Glen Innes Hospital
Manilla Hospital
Singleton Hospital
Armidale Hospital
Cessnock Hospital
Inverell Hospital
Muswellbrook Hospital
Gunnedah Hospital
FWLHD Broken Hill Health Service Nil Complete
No issues identified
MNCLHD Bellingen River District Hospital Nil Complete
Wauchope District Hospital No issues identified
Coffs Harbour Health Campus
Port Macquarie Base Hospital
Kempsey District Hospital
Macksville District Hospital
SWSLHD Liverpool Hospital Nil Complete
Campbelltown Hospital No issues identified
Fairfield Hospital
Bowral Hospital
Bankstown-Lidcombe Hospital
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LHD Sites where re-testing complete Sites remaining Expected completion

to be re-tested date/Status
(Camden – N/A no works in the last 5
years)
NNSWLHD Byron Hospital Nil Complete
Murwillumbah Hospital No issues identified
Health One Pottsville
Tweed Hospital
Ballina Hospital
Casino Hospital
Lismore Base Hospital
Maclean District Hospital
Yamba Community Health
Grafton Base Hospital
NSLHD Manly Hospital Nil Complete
Mona Vale Hospital No issues identified
Ryde Hospital
Hornsby Ku-ring-gai Hospital
Royal North Shore Hospital

SESLHD Prince of Wales Hospital Nil Complete

Sydney & Sydney Eye Hospital No issues identified
The Sutherland Hospital
Royal Women’s Hospital
St George Hospital
WNSWLHD Dubbo Base Hospital Nil Complete
Forbes District Hospital No issues identified
Parkes District Hospital
Gulgong Health Service
Peak Hill Health Service
Eugowra Health Service
Bathurst Health Service
Walgett Health Service
Cowra District Hospital
Orange Health Service
Sydney LHD Canterbury Hospital Nil Complete
Concord Hospital No issues identified
Royal Prince Alfred Hospital
Chris O’Brien Lifehouse
Sydney Dental Hospital
Murrumbidgee Tumut Hospital Nil Complete
LHD Gundagai District Hospital No issues identified
Corowa District Hospital
Young Hospital
Deniliquin Hospital
Hillston District Hospital
Lockhart District Hospital
Griffith Hospital
Coolamon Hospital
Temora Hospital
Wagga Wagga Rural Referral Hospital
St Vincent’s St Vincent’s Hospital Nil Complete
Health Network No issues identified
JH&FMH N/A at the time of request N/A N/A

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LHD Sites where re-testing complete Sites remaining Expected completion

to be re-tested date/Status
Network
ASNSW N/A - no piped gas N/A N/A

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Appendix G – Checking of all NSW Health facility gas outlets for gas
type and concentration
Confirmation of testing
LOCAL HEALTH DISTRICTS
Central Coast LHD Complete
No issues identified
Far West LHD Complete
No issues identified
Hunter New England LHD Complete
No issues identified
Illawarra Shoalhaven LHD Complete
No issues identified
Mid North Coast LHD Complete
No issues identified
Murrumbidgee LHD Complete
No issues identified
Nepean Blue Mountains LHD Complete
No issues identified
Northern NSW LHD Complete
No issues identified
Northern Sydney LHD Complete
No issues identified
South East Sydney LHD Complete
No issues identified
South Western Sydney LHD Complete
No further issues identified
Southern NSW LHD Complete
No issues identified
Sydney LHD Complete
No issues identified
Western NSW LHD Completed
No issues identified
Western Sydney LHD Completed
No issues identified
SPECIALITY HEALTH NETWORK
Sydney Children’s Hospitals Network Complete
No issues identified*
ASNSW N/A - No piped gases
Justice Health & Forensic Mental Health Complete**
Network No issues identified
NSW Health Pathology Complete
No issues identified
St Vincent’s Health Network Complete
No issues identified
Cancer Institute No gas outlets

*During the course of testing for gas type and concentration, an instance of gas outlet panel mislabelling
was identified and corrected; this did not present a risk to patient safety.

**One outlet is not currently operational and is being considered for decommissioning. For this reason, it
was not tested.

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Appendix H – Membership of the Root Cause Analysis investigation

team
Chair: Professor Michael Nicholl, Clinical Director, Division of Women’s, Children’s and Family
Health, Northern Sydney Local Health District

Members:

• Senior Anaesthetist (external to LHD and supported by the Royal Australian and New
Zealand College of Anaesthetists)
• Neonatologist (external to LHD)
• Senior Paediatrician & Clinical Director (SWSLHD)
• Nurse Manager Operating Theatres (SWSLHD)
• Clinical Midwifery Consultant (SWSLHD)
• Patient Safety Manager (SWSLHD)
• Patient Safety Manager (Clinical Excellence Commission)
• Director, Clinical Governance(SWSLHD)
• Manager, Capital Works (SWSLHD)
• Engineer (external to LHD)
• Engineer (independent to NSW Health)

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