Neglect contributed to the death of a 78 year old given a massive overdose in a care home, a coroner has concluded.
Patricia Rosen was given 16 times the proper dose of a painkiller meant for another resident also called Patricia.
She died just hours after arriving at Cedar Court in Wigston, Leicestershire, on 18 February 2013.
The coroner said the unit was short staffed and the agency nurse who gave the drug had poor English and struggled with the drug system at the home.
The inquest at Leicester Coroner's Court had heard nurse Mariana Birsesteanu was left in charge of more than 50 patients the night Mrs Rosen was given the fatal dosage.
Mabel Casyao, the home's deputy manager, told the court she went through how to administer and record the drugs with Ms Birsesteanu.
But with hindsight she should have stayed until all the drugs had been given, she said.
Speaking outside court, Ms Birsesteanu said: "This is a nightmare I will be carrying for the rest of my life.
"It could so easily have been avoided, it just took a second to miss something and it all changed."
In a statement, Mrs Rosen's family said her death was "wholly avoidable" and they hoped the case would serve to remind all involved the safety of residents, and the training of all staff should always be at the forefront of their minds.
At the time of the death, international nurses working in the UK were not made to carry out a language test. This has since changed.
Procedures at the care home have also since changed.
Police investigated but the Crown Prosecution Service decided not to bring any charges.