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Newborn baby dies after being given laughing gas instead of oxygen

Inquest hears of “shocking chain of events” leading to death of John Ghanem in Sydney, Australia

Peter Stubley
Tuesday 13 July 2021 15:22 BST
<p>A newborn baby in an incubator at hospital</p>

A newborn baby in an incubator at hospital

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A newborn baby died within an hour of being mistakenly given laughing gas instead of oxygen, an inquest has heard.

John Ghanem received nitrous oxide because of the botched installation of equipment at the hospital in western Sydney, a coroners court was told.

The blunder had already resulted in a baby girl suffering permanent brain damage just over a year earlier.

However it was only detected after staff discussed the similarities between John's death and another child's death in India.

The day after John's death, the midwifery manager at Bankstown-Lidcombe Hospital made a "high-priority request" for the gas panel in the operating theatre to be tested - but this was not carried out for another six days, according to a report of the inquest in the Sydney Morning Herald.

Donna Ward, counsel to the inquest, said that it was "fortuitous that no other baby had required the provision of oxygen" from the gas panel during that period.

Contractor Christopher Turner, who installed the gas pipeline in 2015, pleaded guilty to a health and safety charge and was fined $100,000 (£54,000) last year.

The inquest at Lidcombe Coroners Court, which began on Monday and is due to last two weeks, will focus on the circumstances of John’s death "to try and minimise the chance of it ever happening again", said Ms Ward.

John, the fourth child of Youssef and Sonya Ghanem, was born by caesarean at 11.54am on 13 July 2016 after doctors detected bacteria linked to neonatal sepsis.

He was placed in a neonatal resuscitation bay when doctors noticed a loose part of his umbilical cord was wrapped around his neck and he wasn’t breathing properly.

“John gave a weak cry but no sustained respiratory effort,” said Ms Ward.

A doctor “tried to stimulate John by rubbing him with a cloth” before using an infant resuscitator to push air into his longs.

He was then given oxygen from a gas line marked oxygen on a wall-mounted panel and CPR but was declared dead by 12.51pm.

“John had lived for just under one hour,” Ms Ward said.

“Ultimately Sonya and Youssef got to spend time with their baby boy, but this was after John had died.

“His death also affected the doctors and nurses at Bankstown-Lidcombe Hospital who had fought so hard to keep him alive. Even after the events, his death made no sense to the treating team.”

In the previous incident at the same operating theatre in June 2016, Amelia Khan suffered brain damage and was not expected to survive longer than a few months.

Now five years old, Amelia suffers from quadriplegic cerebral palsy. Her mother Benish told The Sunday Telegraph last year: "She’s been able to make such a big change in four years imagine what she can accomplish the rest of her life as long as she has the right people by her side."

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