Ruby Chen died at the age of three during an aero-medical inter-hospital transfer. After her death it was discovered that she was inadvertently administered a lethal dose of air through an intravenous fluid line. The air would not have been in the line and Ruby would still be alive today if the intravenous fluid bag was not re-spiked. Re-spiking is the insertion of an intravenous line (or spike) into an already spiked intravenous fluid bag. The coroner recommended intravenous fluid bags should be clearly marked with SPIKE ONCE ONLY and that this be referred to as Ruby’s rule.