South Western Sydney Local Health District
A cross-connection of gas delivery outlets at Bankstown-Lidcombe Hospital led to the serious injury of one newborn baby and the death of another between June and July 2016. During resuscitation attempts the newborns were administered nitrous oxide instead of oxygen. An investigation identified the cross-connection occurred during work performed on the delivery system in July 2015.
Alleged breach
Section 19(2) of the Work Health and Safety Act 2011 (WHS Act), as a person with health and safety obligations prescribed under Sections 32 of the WHS Act.
Reasons for accepting the undertaking
- The alleged contravention does not appear to be a section 31 Reckless conduct category 1 offence, which if it was the case, would preclude the proposed undertaking from being accepted.
- The nature of the alleged contravention and the actions taken by South Western Sydney Local Health District in response to the incident are assessed as being appropriate for consideration of an undertaking.
- The strategies proposed in the undertaking have been assessed as likely to deliver long term sustainable safety improvements in the workplace, industry and community
*the undertaking addresses the requirements contained within the Enforceable Undertakings Guidelines.
Summary of undertaking
Activities that South Western Sydney Local Health District will undertake include:
- Roll out of an electronic contractor registration kiosk in acute facilities across South Western Sydney Local Health District.
- Implementation of a risk information system across all departments in South Western Sydney Local Health District and dissemination of learnings and experience to all NSW Health entities.
- Health and literacy program for prominent culturally and linguistically diverse communities in the South Western Sydney Local Health District.
This undertaking has a total expenditure of $536,600.
Date accepted
23 September 2019
Further information
View the full South Western Sydney Local Health District enforceable undertaking.