Morphine overdose

A disciplinary hearing was told how a premature baby was given a day's morphine overdose in just 11 minutes after a mix up over syringes.

Eva Serenio, a staff nurse, was found guilty of misconduct at a hearing of the Nursing and Midwifery Council (NMC).

While working at Bradford Royal Infirmary in 2004 she admitted that she gave the morphine solution to a baby born at 27 weeks, named only as Baby A.

She had believed she was giving the child human albumin solution (HAS).

The conduct and competence committee of the NMC ruled Ms Serenio's "fitness to practise" was impaired after hearing she had not checked the label on the syringe.

Given medication intended for another patient
The result was that Baby A, who weighed just 0.8 kgs, was given morphine intended for another patient.

David Glendinning, for the NMC said: "Effectively - in addition to the prescribed morphine - Baby A had received approximately the equivalent of 24 hours of treatment with morphine over a period of 11 minutes."

The overdose mistake was discovered by a pharmacist during routine rounds in the unit.

The hearing was told how, when asked by the nurse in charge why Baby A had Baby C's morphine she "put her hand across her mouth, gasped and said it should be HAS".

Ms Serenio, who up until the error had 24 years of "unblemished" service, wept during the hearing and told the committee: "It has really devastated me because I love taking care of babies."

The committee adjourned until Wednesday to consider what, if any sanctions, they would take against Ms Serenio.

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