The Derriford nurse said she had no explanation for the error

A nurse set up the equipment incorrectly for administering diamorphine, the medical name for heroin, an inquest in Plymouth heard.

Retired painter and decorator Arthur Berry was admitted to Plymouth's Derriford Hospital on 29 August last year after collapsing at his home.

His family has called for tougher rules to prevent another mistake.

Diamorphine is a pharmaceutical form of heroin

Mr Berry, of Tennyson Gardens, Plymouth, was given antibiotics for a chest infection after he was admitted to the hospital.

But his condition worsened and by 4 September hospital doctors suspected he had terminal pneumonia and would die shortly.

The following day he was prescribed 15mg of the potent painkiller diamorphine to be administered gradually by a "syringe driver" over a 24-hour period.

At noon on 5 September nurse Margaret Bakheit set up the equipment - but she used a one-hour pump instead of a 24-hour pump.

"I cannot explain why I did so Nurse Margaret Bakheit

She also failed to adjust the settings so it would release the drug more gradually.

She told the inquest: "I cannot explain why I did so.

"Nobody pointed out the error."

Earlier consultant forensic pathologist Dr Allen Anscombe said it was his assessment that Mr Berry was "terminally ill and was expected to die anyway" at the time of the mistake.

Coroner Nigel Meadows ruled that the dose of diamorphine "contributed" to Mr Berry's death.

He said: "Sadly sometimes when the medical profession makes errors, the consequences can be minor or they can be more serious."

Following the verdict Mr Berry's family said in a statement: "We do hope that more rigid procedures are put in place, and that they are closely monitored. It is our profound wish that no similar incidents occur in the future."