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Report on radiation overdose due Radiation report identifies error
(about 2 hours later)
A report into a how a teenage cancer patient was given massive overdoses of radiation is to be published later. A report into a how a cancer patient was given overdoses of radiation has identified a change to working systems "without thought for patient safety".
Lisa Norris, 16, received at least 17 overdoses during radiation therapy for a brain tumour at the Beatson Oncology Centre in Glasgow. Lisa Norris, 16, received overdoses during therapy for a brain tumour at the Beatson Oncology Centre in Glasgow.
She died last week at her home in Girvan, Ayrshire, nine months after the overdoses, which at the time were blamed on "human error". She died last week at her home in Girvan, Ayrshire, nine months after the overdoses, put down to the work of an "inexperienced treatment planner".
The Scottish Executive ordered an independent investigation. Ministers said the report showed "significant lessons" must be learned.
Lisa had initially been diagnosed with a brain tumour in October last year.Lisa had initially been diagnosed with a brain tumour in October last year.
It is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly Health Minister Andy Kerr
She received the overdoses of radiation therapy during treatment in January, leaving her with burns on the back of her neck and head.She received the overdoses of radiation therapy during treatment in January, leaving her with burns on the back of her neck and head.
In the weeks before her death, Lisa had been recovering from surgery to remove fluid from her brain.In the weeks before her death, Lisa had been recovering from surgery to remove fluid from her brain.
Her father Ken said he believed the radiation was the cause of Lisa's death.Her father Ken said he believed the radiation was the cause of Lisa's death.
'Immediate action'
Immediate inspections of Scotland's five Cancer Radiotherapy Centres will also take place in the wake of the report.
Health Minister Andy Kerr said: "I am determined that lessons are learned.
READ THE REPORT Report into unintended overexposure of Lisa Norris [29KB] Most computers will open this document automatically, but you may need Adobe Reader Download the reader here
"It is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly.
"The Inspector's report has been a vital exercise in establishing what went wrong in the treatment of Lisa Norris, and why.
"His recommendations are aimed at minimising the risk of any possible recurrence."
The report was compiled by the Inspector appointed by Scottish Ministers for the Ionising Radiation (Medical Exposures) Regulations 2000.
It outlines a number of key safeguards that should be in place to ensure patient safety during radiotherapy.
In a letter to NHS Greater Glasgow and Clyde, Mr Kerr said he had made it clear he now expects action to be taken at the Beatson.
The Beatson centre, which is run by NHS Greater Glasgow and Clyde, has carried out at least 29,000 courses of radiotherapy treatment since 1985.The Beatson centre, which is run by NHS Greater Glasgow and Clyde, has carried out at least 29,000 courses of radiotherapy treatment since 1985.