(e) Instructing workers, in particular Mr Heasman and Mr Turner, that testing should be undertaken at the completion of the work and, in particular, that the testing should:
Determine the identity of the gas being emitted from the new ports was correct by performing a cross-connection test;
Determine the concentration of oxygen being emitted from the new ports was correct and that there was no contamination; and
Be conducted in the presence of a member of BLH experience in the administration of medical gases, or
Be conducted by the anaesthetist in charge or a delegated anaesthetist.
- The operational tests were required to be performed in the presence of a member of the health care facility experienced in administration of medical gases to patients in accordance with Clause 5.7.1 of the Standard.
- Mr Turner gave a description of his testing procedure at A111 in Exhibit O. In that response it is clear that he had done the work before and knew what he was required to do. He was clearly aware of the requirements to satisfy the Standard. It is impossible to conclude that he complied with the terms of the Standard, as had he done so, the incidents would not have occurred.
- The evidence indicates that the testing of the oxygen outlet in OT8 may not have been completed by Mr Turner at all. It is impossible that if the testing regime had been properly performed, the cross-connection would not have been detected. The BOC forms detailed the Tests for Cross Contamination and Tests for Zone Isolation Valves. The forms detail that the testing is in accordance with the Standard.
- The testing forms were completed by Mr Turner. The Medical Gas Outlet Test Form (Exhibit E) was completed by Mr Turner. Whilst there are some errors with regard to the entries on the form for the pressure and flow rates in OT5, I accept that these are simply mistakes in the transposition of the figures.
- However, the entries on the form for OT8 cannot be correct. The entries were made by Mr Turner, and were signed as witnessed by Mr Brightwell. As was ultimately revealed, the oxygen outlet in OT8 was connected to nitrous oxide. If Mr Turner had done the tests as required by the forms that he signed, this error would have been picked up. I accept that Mr Turner knew that he had to perform each of the necessary operational tests prescribed in the Test Certificates. I accept that he knew that the testing had to be witnessed by a person as designated in the Standard as someone 'competent in medical gas testing and verification of piping systems'.
- Test Certificate - Form 15. This is the handover instruction which makes reference to the Standard. Mr Brightwell signed that handover document as having witnessed that Test for Gas Purity. The document refers to the Standard and provides the methodology as to how the tests are to be conducted. This document is of great significance as the facility cannot be utilised by the hospital until the handover is complete. In so signing, it is incumbent upon Mr Brightwell to check and witness that all of the works have been done properly. Ms Larkin (Transcript p239 and 240) indicates that the direct responsibility for ensuring that the system for piping medical gases, including oxygen, was serviced, maintained and kept up to standard was held by Mr Brightwell.
- Her evidence (Transcript p240) was:
'Q If Mr Brightwell had not signed the handover documents, then the facility, the newly installed panels, would not have been able to be used by hospital staff?
A Correct
Q It was only the fact that he, in conjunction with Mr Turner, signed the relevant documents that allowed hospital staff access to and use of those facilities?
A Correct.'
- It was therefore his responsibility to ensure that the area in which the works had been done underwent the appropriate commissioning and handover, before the theatres could be utilised again.
- It is inconceivable to me that both Mr Turner and Mr Brightwell did not understand the necessity to do the testing, and the potential consequences if the testing was not done, or was not done adequately. Whilst there is no evidence before me that Mr Turner did not do the required testing, or that he did not do it competently, on all the evidence I accept that nonetheless he falsified the testing documents.
- There is a dispute in the evidence as to the circumstances under which Mr Brightwell signed the documents as having witnessed the testing. His evidence before me was that Mr Turner told him the testing had been done, and did not ask him to witness the testing but simply to sign the forms as he, Mr Turner, had actually done the testing.
- Mr Turner's s 155 Notice contains an answer that when he has asked Mr Brightwell to come and witness the testing, Mr Brightwell replied as follows:
'I'll take your word for it'.
- I am of the view that Mr Turner has entered a guilty plea to a charge brought by SafeWork NSW with regard to these incidents.
- I believe that Mr Turner had completed the paper work without performing the testing and thus falsified the records. I also believe that whatever was said or not said to Mr Brightwell about witnessing the testing, he signed the testing forms as having in fact witnessed the testing, but he clearly did not and has conceded such before me in court. Necessarily then, he was also complicit in signing documents that did not reflect that he had not witnessed any of the testing. The combination of the falsification of the documents by Mr Turner and Mr Brightwell had the most disastrous and tragic consequences.