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| Version 5 | Version 6 |
|---|---|
| Radiation report identifies error | Radiation report identifies error |
| (4 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 Minister | It 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 here | 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 |
| "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." |