SADLY MISSED: Three-year-old Ruby Chen.
SADLY MISSED: Three-year-old Ruby Chen. Contributed

Ruby Chen inquest finishes

A $1 intravenous bag would have made all the difference for little Ruby Chen.

An inquest has found the three-year-old died of a severe air embolism because a partly empty IV bag was respiked and used to administer saline fluids.

The air entered Ruby's blood about 31 minutes into the flight, Central Queensland Coroner David O'Connell said while delivering his findings yesterday.

If a new IV fluid bag had been used "then young Ruby would be with us today", Mr O'Connell said.

Respiking the bag with a new "giving set" allowed air to enter the bag. The IV bag was then placed inside an opaque pressure bag, which forced its contents, the saline fluid and air, into the cannula in the back of Ruby's hand, the Coronial Court was told.

If an infusion pump had been used then once it had detected air it would have sounded an audible alarm and stopped pushing fluids into Ruby, the court was told.

Ruby had been a patient at the Blackwater Hospital and the decision had been made to transfer the little girl to Rockhampton hospital for further care.

Queensland Ambulance Service was tasked by Retrieval Services Queensland to collect Ruby in Blackwater and transport her to Rockhampton.

She was pronounced dead at 8.40pm on August 9 in Rockhampton after her condition deteriorated during the flight.

Mr O'Connell said he heard a lot of evidence over whether the reused IV bag was respiked by a nurse at the Blackwater Hospital then handed to the paramedic, or respiked by the paramedics themselves.

Mr O'Connell found it was the lead paramedic who respiked the partly used IV bag. He said the medical treatment given to Ruby at both the Blackwater and Rockhampton hospitals "did accord with best practice".

Maurice and Blackburn medical negligence principal Sarah Atkinson, on behalf of Ruby's father Charlie Chen, said he was "relieved and happy" to reach this point and was hoping to get some closure now the finding had been delivered.

"Clearly nothing that can be done now can bring back Ruby, but Mr Chen welcomes the changes that have been suggested by the Coroner," Ms Atkinson said.

Mr Chen hoped the changes would be implemented to prevent a similar tragedy.


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