Charges have been laid over the accidental yet fatal gas mix-up at Bankstown-Lidcombe Hospital, which claimed the life of one newborn - and left another with serious brain damage.
Five parties have been charged by Safe Work NSW over the incident, which saw the babies incorrectly given nitrous-oxide instead of oxygen in 2016.
Shadow Health Minister Walt Secord has called for changes within the South Western Sydney Local Health District to ensure other families never "experience the same pain".
“This has been a heart-breaking tragedy for two families," he told the Triple M Newsroom.
“It is impossible to fathom what these two families must be suffering.
“While Health Ministers and State Governments will come and go, this tragedy will remain with the families forever.
"Our hearts go out to them."