An inquest into the death of a newborn baby at Bankstown Lidcombe Hospital has heard it took a week to discover the gas lines had been mixed up at installation.
Baby John Ghanem lived for just one hour after birth, given nitrous oxide instead of oxygen during resuscitation in 2016.
Amelia Khan was left with severe brain injuries in similar circumstances a month earlier.
READ MORE: Hospital subcontractor fined $100k over gas mix up that killed Sydney newborn
Today Lidcombe Coroner's Court was told the "shocking chain of events" made "no sense" to staff to begin with.
"It should be noted that his death also affected the doctors and nurses at Bankstown Lidcombe Hospital who had fought so hard to keep John alive."
One nurse had heard of a strikingly similar event in India and lodged a request that the gas lines be tested.
READ MORE: Charges over deadly gas mix-up at Bankstown-Lidcombe Hospital dropped
But the court heard they were not checked by BOC until a week later, exposing the tragic error.
Installer Christopher Turner was fined $100,000 for failing to test the lines in accordance with the Australian standard when he signed off on the work.
Counsel Assisting said the inquest would try to build on what has already been done.
"What would any of us expect to see happen … to try to minimise the chance that a similar thing could ever happen again."
It will examine what changes have been made and if more has to be done.
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