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Radiation report identifies error Radiation report identifies error
(20 minutes 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". A report into 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 overdoses during 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, put down to the work of an "inexperienced treatment planner". She died last week at her home in Girvan, Ayrshire, nine months after the overdoses, put down to the work of an inexperienced staff member.
Ministers said the report showed "significant lessons" must be learned.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.
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.
It is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly Health Minister Andy Kerr
The report was compiled by Dr Arthur M Johnston, the inspector appointed by Scottish Ministers for the Ionising Radiation (Medical Exposures) Regulations 2000.
He said: "A change was made to a system of working without adequate analysis of the possible consequences for patient safety.
"An inexperienced treatment planner therefore failed to identify a critical consequence of this change and a critical error in data passed unidentified to the radiographer responsible for treatment delivery."
By the time the error was identified, Lisa had received 19 out of 20 treatments - and a dose of radiation 58% higher than the dose prescribed.
'Immediate action''Immediate action'
Dr Johnston said he had learned of Lisa's death during the final stages of preparation for the publication of the report.
"All of those who have assisted me in conducting the incident investigation wish to join with me in expressing our sincere condolences to Lisa's family for their sad loss," he added.
Immediate inspections of Scotland's five Cancer Radiotherapy Centres will also take place in the wake of the report.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.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 hereREAD 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."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."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.""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.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.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.
Recommendations include raising awareness of the need for the maintenance and implementation of quality working systems in all areas where patient safety is of concern.
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.
Dr Johnston added: "I should offer my assurance that my investigations have left me in no doubt of the dedication of the Beatson staff and of their commitment to the safety of patients in their care."