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Radiation report identifies error Radiation report identifies error
(about 1 hour later)
A report into 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 "critical error" in her treatment plan by inexperienced staff.
Lisa Norris, 16, received 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 Girvan, Ayrshire, nine months after the overdoses, put down to the work of an inexperienced staff member. She died last week at her home in Ayrshire nine months after a dose of radiation 58% higher than prescribed.
Ministers said the report showed "significant lessons" must be learned. "Immediate" inspections of Scotland's five cancer radiotherapy centres will take place in the wake of the report.
Lisa had initially been diagnosed with a brain tumour in October last year. The cause of Lisa's death is not known at this stage.
She received the overdoses of radiation therapy during treatment in January, leaving her with burns on the back of her neck and head. She was 15 when she received repeated overdoses at the Beatson where she was being treated for a brain tumour.
Her father Ken said he believed the radiation was the cause of Lisa's death. READ THE REPORT href="http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/27_10_06_lisa.pdf" class="">Report into unintended overexposure of Lisa Norris [29KB] Most computers will open this document automatically, but you may need Adobe Reader href="http://www.adobe.com/products/acrobat/readstep2.html">Download the reader here
It is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly Health Minister Andy Kerr She had begun the therapy in January, after chemotherapy at Yorkhill Hospital in Glasgow.
The report was compiled by Dr Arthur M Johnston, the inspector appointed by Scottish Ministers for the Ionising Radiation (Medical Exposures) Regulations 2000. The error came to light because the same treatment planner made the same mistake the next time round for a different patient.
But this time it was picked up by a colleague, an immediate internal investigation was ordered, and this revealed the error in Lisa's case.
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.
"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."
'Sincere condolences'
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.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' Dr Johnston concluded most of the responsibility and "hence any blame" could be attributed to the principal planner.
Dr Johnston said he had learned of Lisa's death during the final stages of preparation for the publication of the report. He 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. It is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly Andy KerrHealth Minister
Immediate inspections of Scotland's five Cancer Radiotherapy Centres will also take place in the wake of the report. He expresses his sincere condolences to Lisa's family.
Health Minister Andy Kerr said: "I am determined that lessons are learned. In a letter to NHS Greater Glasgow and Clyde, Health Minister Andy Kerr said he had made it clear he now expects action to be taken at the Beatson.
READ THE REPORT href="http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/27_10_06_lisa.pdf" class="">Report into unintended overexposure of Lisa Norris [29KB] Most computers will open this document automatically, but you may need Adobe Reader href="http://www.adobe.com/products/acrobat/readstep2.html">Download the reader here He said: "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.
"His recommendations are aimed at minimising the risk of any possible recurrence.""His recommendations are aimed at minimising the risk of any possible recurrence."
It outlines a number of key safeguards that should be in place to ensure patient safety during radiotherapy. The report 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. 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".
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." The health board said itsstaff were devastated by what had happened.
Professor Sir John Arbuthnott, chair of NHS Greater Glasgow and Clyde, said: "I can assure the Norris family and the public in general that as a result of this incident and the subsequent inquiry and report that the treatment of rare and complex cancers will be made safer than ever before."
"Significant changes have already been made."