It has been found by a team of investigators that a child, Joshua Elliott, one month in age, died at Sydney Children's Hospital on September 9, 2009 due to insertion of an incorrect catheter in his neck. It has been found that doctors were unable to determine the right catheter because of catheters being wrongly labelled.

The report has revealed that wrong labels on catheters has caused the death of a newly born baby, aged merely one month. It is being said that the child was born with a rare condition known as gastroschisis, in which intestines are affected. Due to the same, he had also started to put on weight at a very small age.

A central venous catheter (CVC) carrying nutritional fluid was inserted into his neck as his treatment in a surgery. It is being said that the tube perforated through one of his veins and the fluid leaked all over around his heart and lungs, says the report. The leakage of the nutritional fluid in his body caused his death to occur.

Dr. Lisa Ewans, resident gastroenterologist told the reporters that CVC tube was not available in the right size and doctors had realized that they did not have a tube so small to be fitted in baby. Also, Dr. Ewans was not able to find the desired size of tube in the storage area of the hospital's intensive care unit.

In the context, Deputy State Coroner Scott Mitchell added that he was expecting to see evidence of statements that the catheters were incorrectly labelled and that right-sized catheter was not available at a time when the baby was set for operation. "I'm just surprised a bit surprised that this lady (Dr Ewans) ... was put in the situation where there's a little baby on the table and all of a sudden the proceduralist discovers the right-sized equipment isn't available", he further affirmed.