A baby boy died just an hour after he was born when doctors mistakenly gave him laughing gas instead of oxygen, an inquest has heard.
The fatal error saw John Ghanem pumped full of nitrous oxide as medics frantically tried to get him breathing at Bankstown-Lidcombe Hospital in Sydney, Australia, in July 2016.
On what would have been his fifth birthday, an inquest at Lidcombe Coroners’ Court was told the oxygen and nitrous oxide pipes in one of the operating theatres had been mislabelled years before.
They were later connected to the neonatal unit without being properly checked – a mix-up which went unnoticed for more than a year.
It also left another newborn baby with significant brain damage when she was similarly ventilated with nitrous oxide two months before John’s birth, The Australian reports.
The court was told that John’s mother Sonya underwent an emergency caesarean on the recommendation of her obstetrician on July 13, 2016.
He was placed in a resuscitation area after doctors noticed a loose part of his umbilical cord had wrapped around his neck and he was not breathing properly, news.com.au reports.
They fitted a mask to try and pump air into his lungs but he failed to respond, so they hooked it up to the pipe they believed to have been 100% oxygen.
But John died after being ventilated with nitrous oxide being piped in from the theatre’s gas panel.
His death stumped the resuscitation team who thought they had done everything correctly.
The error was only picked up by a doctor’s hunch after he noticed striking parallels between the incidents at the hospital and the death of a boy in India due to a mix-up with medical gas.
Engineer Stuart Clifton, who was instructed to investigate the incident in 2017, told the inquest the gas mix-up would have been discovered immediately had the required tests been done.
He said: ‘The simple fact is had they done the tests, then the result, being this investigation, would not have been required.’
The court heard a gas identification test takes less than two minutes to complete.
The inquest continues.
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