A CORONER today recorded a narrative verdict in the inquest into the death of a four-month-old baby who died after he was given ten times the prescribed dose of salt solution.

Notts Coroner Dr Nigel Chapman said Samuel McIntosh died because of a "dreadful mistake" at the Queen's Medical Centre.

He was supposed to be given five millilitres of sodium chloride after his salt levels dropped to a "moderately severe" level.

But the child was instead given 50mls of the solution - ten times what was prescribed - causing him to have dangerously high levels of salt leaving him dehydrated and causing irreparable damage to his brain.

Samuel, of the Arches, Mansfield, died at the Queen's Medical Centre on July 7 last year.

Speaking at his inquest, Dr Chapman said: "There's no doubt that a dreadful mistake took place but drug errors are more common than we know.

"In this case there were two people that made a drug error because of distraction by others.

"Samuel died from complications of an overdose of sodium. This was drawn up incorrectly and administered by two nurses."

Samuel had been born prematurely at 24 weeks and weighed 580g - just a sixth of the normal weight of babies born after full term.

But despite breathing problems and a perforated bowel, he put on weight in hospital and was starting to "hold his own", Nottingham Coroners' Court heard. By June 6 he weighed 2.8kg and was expected to survive.

The inquest heard that Samuel was transferred from the City Hospital to the QMC when he was 18 weeks old because he needed surgery on his abdomen.

He was put on diuretics on June 29 to treat lung problems but on July 4 began to become seriously unwell. His sodium chloride - or salt - levels were low and he was put on one mixture of sodium chloride, potassium chloride and dextrose to maintain his levels. He was then supposed to be given an extra higher dose of sodium chloride to replace that which he had lost.

This was prescribed in the right dose but a later analysis of the mixture he was actually given showed it contained ten times the amount of sodium chloride.

Sister Karen Thomas and staff nurse Louisa Swinburn who administered the solution, said they had understood the prescription and didn't know how the mistake had happened.

Samuel was put on saline as a safe way to bring his sodium chloride levels down, but his brain had already been damaged by the high levels of salt and he started fitting.