The Court sentenced a medical gas fitter to an aggregate sentence of 2 years and 10 months imprisonment (non-parole period of 10 months) for manslaughter and negligent omission causing grievous bodily harm, arising from his failure to conduct mandatory cross-connection and gas identity testing on a neonatal oxygen outlet in a hospital operating theatre, and his falsification of test certificates, which resulted in nitrous oxide being administered to two newborns instead of oxygen. The Court held that a prior conviction and $100,000 fine under the Work Health and Safety Act for the same underlying omissions was relevant to totality and warranted consideration in the overall penalty, but did not encapsulate the criminality of the more serious index offences. The statutory ratio was varied to 30% based on a finding of special circumstances combining approximately 10 years of delay largely not attributable to the offender, prior punishment, good character, and anticipated difficulty adjusting to custody as a middle-aged person with health issues.
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