A mistake over a decimal point caused the death of a Derby baby who was given 10 times the recommended amount of heart medication, a coroner has ruled.
Baby George died at Glenfield Hospital in Leicester
Two nurses gave the wrong dosage to 15-day-old baby George Bartram when trying to reduce his rapid heartbeat.
The massive influx of the drugs caused him to have a cardiac arrest.
Coroner Martin Symington ruled the two nurses were not guilty of neglect, but said a verdict of accidental death would not tell the full story.
"The mistake made by the nurses was a mathematical miscalculation which in other working environments might not have been quite so catastrophic," the coroner said in recording a narrative verdict.
"They made a mistake and they accept that, but it was a mistake any of us could have made."
The baby, who was born with a congenital heart defect, was taken to Leicester's Glenfield Hospital less than two weeks after his birth in March 2002 after experiencing breathing problems.
He died a few days later after being given the drug Digoxin, which slows the rate of heartbeat.
One of the doses was calculated at 220 micrograms when the correct amount should have been 22 micrograms.
Yvonne Jordan and Angela Fitzsimmons told the hearing they checked and double-checked the drug levels before administering the injection to baby George.
Blaming pressure and time on the ward, Ms Fitzsimmons said: "Because we had calculated it both separately and together and checked it to make sure it was accurate to the book, we believed that we were giving the right dose.
"If we had any doubt whatsoever we would not have given the dose."
Following the hearing, George's parents issued a statement which said the couple hoped that lessons had been learned following the tragedy.
The University Hospitals of Leicester NHS Trust said new measures, including new labelling for drug vials, had been put in place for medical staff.
Consultants now have to agree to prescriptions and the drug amount double-checked by pharmacists.
Staff levels have also been reviewed on the ward where George died.