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Radiation report identifies error Radiation report identifies error
(6 days later)
A report into how a cancer patient was given overdoses of radiation has identified a "critical error" in her treatment plan by inexperienced staff.A report into how a cancer patient was given overdoses of radiation has identified a "critical error" in her treatment plan by inexperienced staff.
Lisa Norris, 16, received 19 overdoses during therapy for a brain tumour at the Beatson Oncology Centre in Glasgow.Lisa Norris, 16, received 19 overdoses during therapy for a brain tumour at the Beatson Oncology Centre in Glasgow.
She died last week at her home in Ayrshire, nine months after a dose of radiation 58% higher than prescribed.She died last week at her home in Ayrshire, nine months after a dose of radiation 58% higher than prescribed.
Her father Ken, 51, from Girvan, said: "We are pleased we have now been told what went wrong."Her father Ken, 51, from Girvan, said: "We are pleased we have now been told what went wrong."
Immediate inspections of Scotland's five cancer radiotherapy centres will take place in the wake of the report.Immediate inspections of Scotland's five cancer radiotherapy centres will take place in the wake of the report.
It is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly Andy KerrHealth MinisterIt is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly Andy KerrHealth Minister
Mr Norris added: "We just hope the recommendations will ensure this tragedy does not happen to another family in the future."Mr Norris added: "We just hope the recommendations will ensure this tragedy does not happen to another family in the future."
Lisa was 15 when she received repeated overdoses at the Beatson.Lisa was 15 when she received repeated overdoses at the Beatson.
She had begun the therapy in January.She had begun the therapy in January.
The error came to light because the same treatment planner made the same mistake for a different patient.The error came to light because the same treatment planner made the same mistake for a different patient.
It was picked up by a colleague, an internal investigation was ordered and this revealed the error in Lisa's case.It was picked up by a colleague, an internal investigation was ordered and this revealed the error in Lisa's case.
The cause of the teenager's death is not known at this stage.The cause of the teenager's death is not known at this stage.
Cameron Fyfe, the Glasgow-based solicitor representing the family, said: "What we require is for an expert to let us know if the excessive radiation treatment caused or materially contributed to Lisa's death."Cameron Fyfe, the Glasgow-based solicitor representing the family, said: "What we require is for an expert to let us know if the excessive radiation treatment caused or materially contributed to Lisa's death."
'Minimising risk''Minimising risk'
The report was compiled by Dr Arthur Johnston, an inspector appointed by Scottish ministers.The report was compiled by Dr Arthur Johnston, an inspector appointed by Scottish ministers.
He said: "A change was made to a system of working without adequate analysis of the possible consequences for patient safety.He said: "A change was made to a system of working without adequate analysis of the possible consequences for patient safety.
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
"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.""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."
Dr Johnston concluded most of the responsibility and "hence any blame" could be attributed to the principal planner.Dr Johnston concluded most of the responsibility and "hence any blame" could be attributed to the principal planner.
Health Minister Andy Kerr said: "It is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly.Health Minister Andy Kerr said: "It is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly.
"Recommendations are aimed at minimising the risk of any possible recurrence.""Recommendations are aimed at minimising the risk of any possible recurrence."
The Beatson, which is run by NHS Greater Glasgow and Clyde, has carried out at least 29,000 courses of radiotherapy treatment since 1985.The Beatson, which is run by NHS Greater Glasgow and Clyde, has carried out at least 29,000 courses of radiotherapy treatment since 1985.
Professor Sir John Arbuthnott, chair of the health board, said: "The treatment of rare and complex cancers will be made safer than ever before.Professor Sir John Arbuthnott, chair of the health board, said: "The treatment of rare and complex cancers will be made safer than ever before.
"Significant changes have already been made.""Significant changes have already been made."