WHS ACT & Procedure Ingonored: One Child Dead, One Child Severely Disabled.

Published by HSE Direct | March 2026 | Case: R v Turner [2026] NSWDC 18 (26 February 2026)

“Amelia suffered severe brain damage because of exposure to the nitrous oxide which caused birth asphyxia… She requires constant care and this will not improve. Amelia is legally blind, confined to a wheelchair, she is unable to swallow and is fed through a PEG, she is incontinent, she is unable to speak and has limited methods to communicate… It is opined her anticipated lifespan has been diminished. With assistance she has been able to attend school. Her situation evidences the continuing impoverishment she endures consequent to the high level of grievous bodily harm she sustained. Amelia is much loved and her family, with professional assistance, provide her with her essential care requirements.” – NSW District Court Judge Nicole Noman, R v Turner [2026] NSWDC 18

On 26 February 2026, Christopher Laurie Turner, 64, was sentenced to two years and 10 months in prison, with a non-parole period of 10 months, after pleading guilty to manslaughter by criminal negligence and causing grievous bodily harm by negligent act. He was also placed on NSW’s Child Protection Register for eight years.

Two babies. One dead. One permanently and catastrophically injured. The cause: a WHS shortcut – skipping gas pipeline tests that would have taken less than 10 minutes to complete. This is not a hypothetical risk scenario. This is what happens when duty holders treat safety checks as optional.

What Happened

In 2015, South Western Sydney Local Health District (SWSLHD) engaged BOC Ltd to install, test, and commission gas delivery lines to operating theatres at Bankstown-Lidcombe Hospital in NSW. BOC contracted Turner – the director and sole employee of Pro-Med Services Pty Ltd – to perform the work.

During installation, a nitrous oxide pipe was mistakenly connected to the oxygen outlet on the neonatal resuscitation unit. This error was invisible – unless the required gas purity and cross-connection tests were performed. Gas pipework in the ceiling space had been incorrectly labelled since construction work in the mid-1990s, creating a latent risk. That risk could only be discovered by testing.

Turner did not conduct the tests. Instead, he falsely declared on the test forms that he had completed them, recording an oxygen concentration of 100 per cent. He signed the final test certificates. An SWSLHD engineer co-signed them as a witness – despite not having observed any testing.

The Consequences

In June 2016, a newborn baby girl – Amelia – was administered nitrous oxide through what was labelled an oxygen outlet during resuscitation. She suffered severe brain damage from birth asphyxia. The gas problem was not identified.

One month later, a newborn baby boy was ventilated with the same toxic gas from the same undetected fault. He died.

The cross-connection test would have taken no more than 10 minutes. Gas identity testing on each outlet would have taken less than 30 seconds per outlet. Had Turner used an oxygen analyser as required by Australian Standards, it would have immediately identified that the oxygen concentration was at or about zero per cent – revealing that the outlet labelled ‘oxygen’ was delivering nitrous oxide.

The Legal Proceedings: WHS Fine First, Then Prison

SafeWork NSW charged multiple duty holders following the investigation. SWSLHD entered an enforceable undertaking of $536,600 in lieu of prosecution in 2019. BOC was found not guilty in early 2020, on the basis that it could not have reasonably foreseen that Turner would falsify the test records.

Turner pleaded guilty to a Category 2 breach of section 28 (Duties of workers) of the Work Health and Safety Act 2011 (NSW) and was fined $100,000 in early 2020.

That was not the end. In 2022, NSW Police charged Turner with manslaughter by criminal negligence and causing grievous bodily harm by negligent act or omission under the Crimes Act 1900 (NSW). After years of court delays, he pleaded guilty to both charges. On 26 February 2026, Judge Noman sentenced him to imprisonment.

The Judge noted that his sentencing options were constrained, to a degree, by the earlier WHS conviction and fine arising from the same conduct. His guilty pleas entitled him to a five per cent reduction in sentence.

What the Judge Said

“There are so many instances where a failure to perform essential work endangers the community. There is a strong compelling need that others be deterred from making rash or convenient decisions failing to comprehend the enduring repercussions.” – Judge Nicole Noman

Judge Noman found that general deterrence and denunciation were of considerable importance, stressing that ‘the risk of death or serious injury from workplace decisions arises with considerable frequency.’

She found Turner’s conduct involved ‘such a great falling short of the standard of care which a reasonable person would have exercised, and which involved such a high risk that death or grievous bodily harm would follow, that doing the act merits criminal punishment.’

WHS Lessons Every Worker and PCBU Must Take From This Case

This case is extreme in its consequences. But the WHS failure at its core is entirely ordinary: a worker skipped a mandatory test and falsified records. It happens in warehouses, on construction sites, in workshops, and in healthcare settings every day. The difference here was the severity of the outcome.

Under the WHS Act, every worker – not just employers and managers – carries a duty of care. Section 28 requires workers to take reasonable care for their own health and safety and the health and safety of others who may be affected by their acts or omissions. That duty does not disappear because a job feels complete, a test seems redundant, or a deadline is pressing.

The lessons for WHS management systems are direct:

• Mandatory testing and verification steps must be documented, non-negotiable, and independently checked – not self-certified by the worker performing the task
• False declarations on safety documentation are not a minor compliance failure – they are a criminal act with potentially catastrophic consequences
• Where work interfaces with critical infrastructure, life-support systems, or vulnerable populations (including neonates, patients, or children), the standard of care is at its highest
• Enforceable undertakings and WHS fines do not foreclose criminal prosecution – a worker can be both fined under the WHS Act and jailed under the Crimes Act for the same conduct
• PCBUs engaging contractors must verify that contracted work – including testing and commissioning – has actually been completed, not simply signed off

Key principle: A worker’s WHS duty under section 28 of the WHS Act is personal and cannot be delegated. Signing a false declaration that safety-critical tests have been completed when they have not is a breach of that duty – and depending on the consequences, may also constitute a criminal offence under the Crimes Act 1900 (NSW).

Your Verification Systems Matter

HSE Direct assists PCBUs, contractors, and project managers to build robust WHS management systems – including contractor governance frameworks, SWMS verification processes, and testing and commissioning protocols – that prevent safety-critical steps from being bypassed or falsified. Contact HSE Direct to discuss your organisation’s WHS obligations.

Sources: R v Turner [2026] NSWDC 18; OHS Alert – WHS shortcut ends in double tragedy, jailing and fine (11 March 2026).