Inspection questions arise after teen injured by medical gas accident at dentist’s office

Medical gas accident prompts questions about inspections

Questions are arising about whether the city acted properly when it allowed a dentist to move into a building that was the site of a March 30 medical gas accident that seriously injured a Tonganoxie youth.

Lawrence City Hall officials confirmed that they do not have a record of whether a required third-party inspection of a medical gas system was conducted at a new dental surgery center operated by Dr. S. Kirk Vincent at 4811 Bob Billings Parkway.

On March 30, Tonganoxie High School senior Austin Stone went to the dental office to have his wisdom teeth removed. After being sedated with medical gas, complications occurred, according to a Web site created by Stone’s family. Stone was taken to Lawrence Memorial Hospital after he stopped breathing, and later was taken to Kansas University Hospital. Attempts to reach members of the Stone family for comment were unsuccessful. As of late Thursday, Stone remained hospitalized but further updates on his medical condition were not available.

The city maintains it was not legally obligated to ensure that a qualified private firm was hired by the builders to inspect the medical gas system, which is used to deliver oxygen and nitrous oxide. But Scott McCullough — the city’s director of planning and development services, who oversees the inspections department — said the city may make changes to the code.

“This event certainly highlights that more can be done to ensure that the inspections are noted in the file,” McCullough said.

McCullough said the city has not been on-site to determine what went wrong with the medical gas system at the building. But since the accident, Dr. Vincent — in a letter to the city’s building inspection’s department — wrote that the accident was caused by improper installation of the medical gas lines.

“The individual manifolds used to connect the oxygen and nitrous oxide were inadvertently transposed,” Dr. Vincent wrote in the April 8 letter. “I was given the go-ahead to begin practicing, and a serious injury occurred to a young man in my office. The problem was solely related to the incorrect hookup of the manifolds.”

According to building permit documents obtained by the Journal-World and 6News through a Kansas Open Records Act request, Lawrence-based Action Plumbing installed the medical gas lines.

An attorney for Action Plumbing said he did not know whether a third-party inspection had been done on the medical gas system. A representative for the general contractor — Lawrence-based Design Build Collaborative — declined to comment.

Some leaders in the Lawrence plumbing industry are raising concerns about whether the city did enough to prevent the accident.

“A mistake was made, but there was a means of not having that mistake happen if there would have been an inspection,” said Denis Wittman, the business officer for the Lawrence chapter of the Plumbers & Pipefitters union.

City officials did make more than 15 inspections of the building, as part of the normal process for any building to receive a building permit in the city, McCullough said.

But city code requires the contractor hire an outside inspection company to conduct a variety of tests on the medical gas system, McCullough said. He said under the code, Dr. Vincent should have received a certificate from the contractor showing the medical gas inspection had been completed.

Dr. Vincent said he never received such a certificate, adding that he was unaware that he was supposed to receive a certificate.

It is unclear whether the city — as the enforcer of the code — had an obligation to determine whether the inspection had been done before city inspectors issued a permit allowing Dr. Vincent to occupy the building.

McCullough said the city’s position is that it had no obligation to verify the medical gas inspection took place.

“As I understand it, we did not take any steps to determine whether it was inspected because it doesn’t fall under our purview,” McCullough said.

In 2007, the city switched its plumbing code from the Uniform Plumbing Code system to the International Plumbing Code system. The switch was made by the City Commission despite formal opposition from the city’s Board of Plumbers and Pipe Fitters. The plumbing board recommended against adopting the International code because members said the International code was often too vague and open to interpretation.

In March 2007 — when the City Commission was debating the subject — commissioners were warned that the International code had lesser medical gas standards, according to the City Commission meeting minutes. Bill Schweitzer, the north central regional manager for the company that publishes the Uniform Plumbing Code, specifically brought up the medical gas issue.

This week, Schweitzer said news of the accident angered him.

“I’m a little bit hot, to say the least, and quite upset,” Schweitzer said. “It is senseless. There’s absolutely no reason for that to happen. None.”

McCullough said the city didn’t agree with the assertion that the International code was weak in the area of medical gas regulation, but said the city was open to adding provisions to the code.

Dr. Vincent, in a letter to the city, has asked that the city be required to verify a proper inspection of medical gas systems has been done before a building is allowed to be occupied.

McCullough said he likely will present that idea to the city’s plumbing board in May or June.

Wittman — the union representative — said he’ll also push for a more thorough review of the entire International Plumbing Code. He fought adoption of the code in 2007, saying it was vague in several areas.

“I’m not going to let this one lay,” Wittman said. “I got beat down on it before and got tired and finally just said it was something we could live with. But now it is clear that we can’t.”