Newborn Died from Being Hooked Up to Laughing Gas Instead of Oxygen, Inquest Hears

A coroner’s investigation has revealed new details surrounding the 2016 death of a newborn who was mistakenly given nitrous oxide instead of oxygen.
July 14, 2021, 5:21am
baby hand hospital
An inquest heard that the pipes carrying oxygen and nitrous oxide into the resuscitation bay where the baby died took a series of "unfortunate twists and turns." Photo by July Semianovich, via Getty Images.

John Ghanem died just an hour after being born at an Australian hospital in July 2016. After being delivered via caesarean section and giving a weak cry, he was hooked up to an infant resuscitator that pushed air from a wall-mounted panel of medical gases into his lungs. The doctor used 50 percent oxygen and then doubled the amount in an attempt to revive the newborn. Unexpectedly, Ghanem’s condition did not improve.


Five years later, an inquest into his death this week has heard that the pipes carrying oxygen and nitrous oxide into the resuscitation bay took a series of “unfortunate twists and turns,” having been mixed up and incorrectly labelled before the Bankstown-Lidcombe Hospital in Sydney opened in 1997, The Australian reported. The pipes were later connected without proper scrutiny to a neonatal medical gas panel in July 2015, according to the newspaper.

Ghanem’s death came less than two weeks after the birth of Amelia Khan in the same operating theatre. In the moments following her birth, Khan, like Ghanem, had required resuscitation, partially via the neonatal oxygen outlet, but showed an “unexpected” reaction to the supposed oxygen. Nitrous oxide – colloquially known as “laughing gas” – is a colourless gas that is commonly used in medical settings for sedation and pain relief.

Khan was moved onto an anaesthetic machine circuit that was connected to a different gas outlet, in what Donna Ward, a counsel assisting the coroner, described as a “step that would prove crucial to Amelia’s survival,” Sydney Morning Herald reported. The girl was nonetheless left with severe and permanent brain damage.


The Lidcombe Coroners Court also heard that the gas mixup would have been identified instantly if the hospital had conducted legally required tests to assess the “suspect panel,” in which case Ghanem’s life could have been saved. Witness and engineer Stuart Clifton, who was engaged by the New South Wales government to investigate the incident, told the court on Tuesday that a gas identification test took just 90 seconds to complete.

Instead, the mixup was only picked up on a hunch when, on the day after Ghanem’s death, a midwifery manager and a paediatrician discussed a strikingly similar case out of India where an 8-year-old child died and an 18-month-old child was left in a serious condition after being mistakenly given nitrous oxide instead of oxygen. The midwifery manager thought it was worth investigating as she had “considered everything else,” and requested that the engineering department test the gas outlets.

The court heard this week that such a request took six days to complete. Ward said it was “fortuitous that no other baby had required the provision of oxygen” from the “suspect panel” during that time.

The contractor who worked on the gas pipeline installation in 2015 was convicted and fined $100,000 last year after pleading guilty to failing to comply with a health and safety duty, and thus exposing Khan and Ghanem to risk of serious injury or death. 

New South Wales District Court judge David Russell said at the time that had the contractor “properly carried out tests of no great complexity for a qualified person which were designed to detect the recognised risk of cross connection, these two tragedies could not have happened.”

The judge also said that the harm caused by the mixup was “almost too awful to contemplate,” adding that “in 43 years as a barrister and then a judge I cannot think of a more tragic case.”

The inquest into Ghanem’s death is set to run for two weeks, and will focus on the cause, manner and circumstances of his death, including his respiratory distress at birth and the installation and testing of the gas pipelines.

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