Baby died after nurse fed her day's worth of food in an hour Maisie was born at the hospital after a planned Caesarean-section on August 16 last year with an atrioventricular septal defect, where the walls in her heart were missing. Ms Bennett and her partner Ryan Waters were told Maisie's outlook was good enough to undergo surgery and she was transferred to the hospital's paediatric intensive care unit. She was fed by an infusion machine which dispensed a specifically-calculated formula called Total Parental Nutrition which was delivered intravenously. It required a nurse to programme how much to give Maisie on an hourly and daily basis when the feed bags were changed. But when the nurse, Martyn Woods, re-configured the machine after replacing a bag he mistakenly entered the daily dose of 210ml under the hourly rate. As a result, she was given 28 times the 7.5ml she should have received in one hour. Mr Woods said he believed the mistake happened after the machine beeped at him, which he thought indicated he needed to re-enter the 24-hour dosage. He told the hearing: "The feed was due to carry on at the same rate as before so I didn't change it from 7.5ml per hour. When the machine bleeped at me I believed it was because it wanted me to re-input the total volume over a 24 hour period, I had not done that previously. As a safety feature if you don't confirm an amount it will tell you and then default back to where you put it in again, I thought it had done that. I recall entering 210ml again and restarting it. William Booth, the Matron and lead nurse for paediatric critical care services at the hospital, said: "The error occurred by incorrectly setting the infusion rate. It should have been 7.5ml per hour but it was actually set at a total volume of fluid to be infused, which was 210ml. The amount Maisie was supposed to receive over 24 hours she actually received in an hour. Maisie went into cardiac arrest on August 22 and doctors were unable to revive her despite 45 minutes of CPR. Eventually her parents, of Ebbw Vale, south Wales, gave their permission for them to stop. The inquest was also told that despite procedures set down in the Medicines Code the hospital did not follow the guidelines requiring two nurses to double check rates of infusions on machines. Although two nurses were present when Maisie's feed bag was changed, only Mr Woods checked the infusion rate after telling the other nurse, Lisa Varlass, that she could return to another patient. The inquest heard that it was not usual practice for two nurses to check unless the staff member was new or specifically asked for help, but it had since become common. Coroner Maria Voisin returned a narrative verdict which said: "Maisie was a patient in the Paediatric Intensive Care Unit. She was born with a heart condition which meant she required surgery. On August 22 she died when she was erroneously over infused with TPN. She added that the hospital had carried out an immediate review of her death and quickly discovered an excessive amount of TPN had been given to the baby. She added that she did not feel that a 'Rule 43' report , where organisations can be asked to consider action to prevent further tragedy, was necessary given the root cause analysis undertaken by the hospital and the changes it had made. Maisie's parents did not wish to comment as they left the hearing.