A newborn baby has died and another has been left brain damaged after they were given doses of nitrogen gas instead of oxygen in a "devastating error" at the Bankstown-Lidcombe Hospital.
The fatal mix-up occurred in one of the hospital's birthing rooms when an outlet in neonatal resuscitation unit emitted nitrous oxide - commonly known as happy gas.
Doctors had instructed "oxygen" be given to the babies, born in June and mid-July, to help them cope after struggling through delivery.
The deadly mistake was only realised last Thursday after paediatrician raised the alarm after the second baby died.
The mother of the newborn who died, Sonya Ghanem, has spoken of her anguish in an emotional interview.
She described through tears the first time she held her baby boy.
"I held my baby. They bring him to the hospital to see him," she told Nine News.
"I told him 'wake up, wake up, what did they do to you?'"
Mrs Ghanem said the hospital was "shocking".
"Coming out of the hospital, holding our capsule, I held nothing in my hand. I came empty-handed, thinking I'll hold my newborn, but no," she said.
The family told The Australian they didn't find out until a week later what happened to the newborn boy.
Ms Ghanem and her husband Youssef - whose other children were born at the same hospital - had their baby boy via Caesarian on Wednesday, July 13.
"They said they needed an emergency," Ms Ghanem's elder daughter Chantal told The Australian.
"They didn't say why. It was rushed, all rushed. We were waiting and waiting and waiting ... then we just find out, you know, gone. The baby's gone."
Chantal said the hospital then contacted them a week later saying "there's some new information about the care your baby was given", which was when they found out about the gas mix-up.
"They admitted it," Ms Ghanem said. "They said 'it's basically our fault'. I lost it when they said that. I just wanted to kill them.
"I am just so angry that an innocent life is gone due to something that should have never happened."
The Ghanem family held a funeral for the little boy on Thursday, July 21.
The other newborn is still fighting for life and remains in a critical condition at hospital.
Health minister Jillian Skinner described it as a "devastating error" and said she was "profoundly sorry" to the grief-stricken families. As her department launched a full-scale investigation, she said: "I reassure the public of the safety of Bankstown-Lidcombe Hospital and hospitals across NSW."
"Bankstown-Lidcombe Hospital has checked all eight operating theatres and found an installation fault in only one theatre," said Ms Skinner adding:
"It has been corrected but that theatre remains closed."
he said the oxygen outlet had been certified by BOC Limited in July, 2015.
In addition to the health department investigation, Ms Skinner confirmed there would be a coronary investigation, a further investigation involving the south west Sydney facility chaired by an independent obstetrician, and an interim report provided to her within the week which she would make public.
She said BOC would conduct its own inquiry and the findings would be shared with NSW Health.
Speaking at a media conference in Sydney Tuesday morning, Ms Skinner said she was confident only two babies had been affected.
Ms Skinner said she would speak with both families on Tuesday. When asked why it took days for the families to be informed of the fatal error, Ms Skinner said the families had "asked for their privacy to be respected".
Opposition health spokesman Walt Secord last night described the deadly bungle as 'every parent's worst nightmare".
"It is astounding and shocking," Mr Secord said. "There has to an independent, external investigation, separate from that conducted by the Department of Health."
Mr Secord said the findings of that independent inquiry must be released to the public.
Government sources claimed information on the bungle had not been released yet because the families had wanted more time before the issue became public.
An "exhaustive investigation" had found no other babies than the pair had been affected despite the bungle not having been identified for weeks.
South Western Sydney Local Health District is conducting a formal investigation to determine if Bankstown-Lidcombe Hospital staff followed protocols which may have detected the installation error last year.
Secretary of NSW Health Elizabeth Koff has advised the state's 15 Local Health Districts and two specialty networks have urgently reviewed their protocols for ensuring medical gas outlets are correctly installed and verified in compliance with the Australian standards.
During Tuesday's media conference Ms Koff admitted: "Unfortunately we failed as a system in the delivery of these two babies."
Mr Secord said: "It can't just go to the Minister and be covered up."
On its website BOC states that it sells "medical nitrous oxide" and "medical oxygen" to healthcare facilities.
Nitrous oxide is commonly known as laughing gas. The colourless gas is commonly used for sedation and pain relief, often used by dentists and medical professionals to sedate patients undergoing minor medical procedures.
BOC, states that the nitrous oxide (n20) it sells is used as an anaesthetic and analgesic agent.
The Australian Drug Foundation, on its website, warns that if a large amount of nitrous oxide is inhaled it can result in a loss of blood pressure, fainting and heart attacks.
"This government has the tendency to commission reports and then not release them
and show what the report actually reveals."
Mr Secord said the incident was a sign of the enormous pressure that the NSW health system is under.
"This is the human cost of cuts to the health system.
"When you tear $3 billion out of the health budget, staff are under pressure and mistakes happen."
Originally published as 'Wake up, what did they do?'