A medical mix-up with tragic repercussions sparked an EA submission to the NSW Government.

In 2016, two newborns were given nitrous oxide instead of oxygen after lines were mixed up in the operating theatre at Bankstown-Lidcombe hospital. The Biomedical College has helped develop 12 recommendations to avoid future tragedies. 
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A medical mix-up with tragic repercussions sparked an EA submission to government

In June 2016, newborn Amelia Khan was accidentally given nitrous oxide instead of oxygen after lines were mixed up in the operating theatre at Bankstown-Lidcombe Hospital, sustaining life-long brain injuries. A month later, baby John Grenham died in similar circumstances.


The subsequent successful court action - which saw the installation company admit to lying about testing and fined $100,000 - was cold comfort for Amelia’s family, who led the call for changes to existing legislation.


Engineers Australia has also lent its weight to the issue, making what EA National Public Affairs Manager Jonathan Russell describes as a “critically important” submission in response to the proposed Regulatory Scheme for Medical Gases – Consultation Paper (July 2020).


“Sadly, it took the tragedies of John and Amelia to highlight the inadequacy of existing regulation and licensing, which failed woefully in ensuring the necessary safety standards,” said Jonathan.


The EA submission, which was written by EA Senior Policy Advisor, Sybilla Grady, in close collaboration with the EA Biomedical College, made twelve recommendations to ensure the regulations provide maximum benefit.


“Submission work is an impactful way for EA to utilise the expertise of members in our advocacy efforts and in this instance the Biomedical College made a number of compelling recommendations that were not included for discussion in the Government’s paper,” said Jonathan.


“Engineers Australia exists for the benefit of the community and providing advice to ensure government policy and regulation keeps the public safe is perhaps the ultimate community benefit.”
EA’s top 4 recommendations

1. It is critical to define four distinct areas relating to medical gas pipeline distribution systems which must be included in the licensing framework in relation to medical gases: engineering design; installation; commissioning; and servicing, inspection, testing and maintenance. The consultation paper did not distinguish between these stages of operation for medical gas equipment.

2. Engineers Australia has identified two additional compliance and enforcement provisions: These are measures that EA members identified which were not included in the consultation paper.

  • that the design of medical gas pipeline systems must be completed by competent and qualified professional engineers, engineering technologists or engineering associates, and;
  • that serious consideration should be given to introducing restricted or limited licences for servicing of the terminal outlet, replacement of aged seals and the service and maintenance of medical gas equipment distal to the wall outlet or other Non-Interchangeable Screw Thread (NIST) fittings where the gas pipeline system terminates.

3. In implementing the proposed regulation and licensing framework, a transition period to provide for continuity of seravice provided by those medical gas pipeline system installers who have appropriate knowledge and experience, but not necessarily the formal trade qualifications introduced by the new regulations, is imperative. Transition policy was not flagged in the consultation paper.

4. Legacy systems installed prior to 1998 should be reviewed to ensure compliance with AS 2896:2011. There are several systems in operation which are not compliant with current standards. A review of these systems was not flagged in the consultation paper.