A tiny premature baby received the equivalent of 24 hours of morphine treatment in a period of just 11 minutes after a mix-up by a nurse over syringes.

Eva Serenio, 49, a staff nurse in the neo-natal unit of Bradford Royal Infirmary, administered a syringe of morphine solution to a baby, born at 27 weeks and weighing fewer than 2lbs, believing she was giving him human albumin solution (HAS), the Nursing and Midwifery Council was told.

The baby has since died.

The alarm was raised after a pharmacist made the discovery on a routine check of medication charts and notes on babies in intensive care and high- dependency at the unit on September 20, 2004, the disciplinary hearing in London was told yesterday.

He noticed Baby A (as the baby was referred to at the hearing) had two syringes of medication infusing - one containing morphine in accordance with the medication chart, and the other had the name of another baby on the label, identified during the hearing as Baby C. 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."

When Miss Serenio was 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".

At a disciplinary hearing later, Miss Serenio's Royal College of Nursing representative stated that, although there was no actual detailed checking procedure and the checking policy was not "explicit" she accepted that she did not follow the correct procedure.

Mr Glendinning added: "She had made a serious drug administration error and did not dispute the fact. The respondent (Miss Serenio) felt deep regret and sorrow."

Miss Serenio has admitted a charge of failing to perform an adequate checking procedure on September 20, 2004 for the administration of HAS to Baby A and, in error, administering to Baby A morphine solution by syringe driver which was prescribed for Baby C.

She has admitted misconduct in relation to the charge. She further admitted a charge of failing to perform an adequate checking procedure on January 30, 2005 when handing over discharge medication - namely eye drops and folic acid - to the family of a baby named as Baby B, who was born at 36 weeks and weighing just over 3lbs.

Miss Serenio has also admitted misconduct in relation to this charge.

The conduct and competence committee of the NMC was told that at the relevant time the neo-natal unit of Bradford Royal Infirmary was a 32-bedded unit with three nurseries staffed by ten nurses on a shift.

Nursery one had 12 beds in total, five of which were intensive care and high dependency beds.

In September 2004 nursery one's refrigerator had controlled drugs including morphine, in the lockable third drawer.

Human albumin solution was contained in bottles in the bottom drawer for use when it was prescribed.

Mr Glendinning said the morphine treatment for Baby C had been drawn up and correctly labelled but had not been used as it had not been needed for a procedure.

He said it had been placed in the bottom drawer of the fridge in nursery one by another staff nurse - in the same drawer as a syringe of HAS solution which had been prepared earlier for Baby A.

It was "accepted" that this was not the correct location for morphine syringes, Mr Glendinning told the hearing, which were normally stored in the third drawer down.

The hearing was told that Miss Serenio mistakenly removed the morphine solutions intended for Baby C from the fridge, failing to check the label.

She carried out a number of checks, the committee was told, including approaching another staff nurse for help in verifying details. But this second staff nurse also failed to check the label on the syringe, the hearing was told.

The committee heard that Philippines-trained Miss Serenio worked in her country of birth and in the Middle East before coming to the UK to find higher paid work in 2002.

She had an "unblemished" record before the errors took place at the end of 2004 and at the beginning of 2005.

She was given a written final warning and temporarily suspended by the Bradford Hospitals Trust after the morphine overdose was discovered, and was ordered to undergo a programme of re-training and support.

She was sacked by the BRI in March 2005 after her second error in relation to Baby B was discovered and is now working in a nursing home with people with mental health and "challenging behaviour" the hearing was told.

The hearing continues.