NURBN 1001: The Tracey Baxter Case Study - Assessment

A six-year-old child, Tracey Baxter, was admitted to hospital for a routine tonsillectomy.

The operation was performed at the commencement of the afternoon list at 1300 hrs and the child was in the recovery room at approximately 1400 hrs. Just prior to the surgery, an intravenous (IV) line was inserted and the child received 300mL of normal saline during the surgery.

At the conclusion of the operation, the surgeon wrote on the IV order chart that the child was to continue to receive 60mL per hour of the saline solution. The registered nurse in the recovery room commenced an observation chart on the child, but did not commence a fluid balance chart, which was later commenced in the childrens ward. The nurse working in the recovery room made some record of Traceys pulse rate and wrote that the child was to have as much fluid as possible in the ward.

Tracey returned to the ward at approximately 1500 hrs, the fluid balance chart was commenced and observations continued. At 1630 hrs a further litre of IV dextrose/saline fluid was commenced, which was completed by 0200 hrs the following morning. A further litre was commenced by the registered nurse on night duty. By 0900 hrs the same morning, Tracey had received 700mL of that litre (this figure is not evident from the fluid balance chart, but this fact was established at the Coroners inquest). The IV fluid intake from the time of the surgery until 0900 hrs the morning after the surgery was three (3) litres.

The observation chart reveals that Traceys observations continued ad hoc. A critical examination of her pulse rate demonstrates a slow but steady decline and one section of the nurses notes reveals that the childs pulse rate went as low as 48 b/min.

The following record extracts were written by the registered nurse on night duty:

1200 hrs: Patient very distressed twitching, screaming, eyes glazed, vomiting bile. Obs satisfactory. Dr notified, ordered stat maxolon 3.5mg IMI given 12.45 am. Voiding well. Maxolon helped only a little, vomiting continued but twitching became less movements more rational. Pupils still dilated.

0415 hrs: Child had a fit lasting about 3 mins, afterwards she had a high pitched wail, her limbs were rigid, her tongue protruded P 48/b. Child has been afebrile throughout. Dr notified.

Following the incident at 0415 hrs, Traceys doctor came to the hospital and administered IV Valium and IM Dilantin to control the fitting. He also reduced the IV fluid order to 40mL per hour, but he did not examine the fluid balance chart, as he presumed that Tracey had been receiving what he had originally ordered (60mL per hour).

Arrangements were made for a specialist consultant to see Tracey later that morning; however, she had a cardiac arrest at 1000 hrs from which she never regained consciousness. She died a short time later.

Please take a moment to deep breathe and recover. This is a pretty awful case.

Since 1979, when this incident occurred, many policies and protocols have beenwritten, so hopefully something as tragic as this will not happen again.