A premature baby, Poppy Davies, died after being given a ''massive overdose'' of glucose following a series of blunders at London's Great Ormond Street Hospital.
Poppy was transferred to the leading children's hospital in London for specialist care after she was born three months early on Christmas Eve last year, in Basildon, Essex.
But she died after a "domino effect" of mistakes, an inquest was told.
Rebecca Tite, a trainee nurse, who had spent just three weeks in the hospital's neonatal intensive care unit, set up a machine supplying her with glucose incorrectly, flooding her body with the solution.
The levels of glucose in Poppy's blood rose to 20 times the maximum level they should have been, causing ''devastating effects'' to her body, St Pancras Coroner's Court in central London heard.
The machine that nurses would have preferred to use to give Poppy glucose would have prevented an accidental overdose being given to her, the inquest heard.
But the equipment was not available after being taken away to help threat a five-year-old boy suffering from meningitis who had needed it urgently.
Both Mrs Tite and Claire Kirk, the senior nurse on duty on January 11, the day of the overdose, failed to check the safety clamp on the syringe that was then used to provide glucose.
As as result, instead of being carefully measured, a free flow of glucose entered Poppy's bloodstream and circulated for over an hour.
The nurses then failed to respond to alarms that sounded in the baby's cubicle which could have alerted them to the fatal error, as they were treating her for breathing problems instead.
Doctors eventually tried to save Poppy's life by giving her insulin but she died on February 1.
But Irony Is, It's No Longer Shocking....
44 minutes ago