This article is from the source 'bbc' and was first published or seen on . It will not be checked again for changes.

You can find the current article at its original source at http://news.bbc.co.uk/go/rss/-/1/hi/scotland/glasgow_and_west/6090266.stm

The article has changed 7 times. There is an RSS feed of changes available.

Version 3 Version 4
Radiation report identifies error Radiation report identifies error
(about 5 hours 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.
"Immediate" inspections of Scotland's five cancer radiotherapy centres will take place in the wake of the report. Her father Ken, 51, from Girvan, said: "We are pleased we have now been told what went wrong."
The cause of Lisa's death is not known at this stage. Immediate inspections of Scotland's five cancer radiotherapy centres will take place in the wake of the report.
She was 15 when she received repeated overdoses at the Beatson where she was being treated for a brain tumour. It is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly Andy KerrHealth Minister
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 Mr Norris added: "We just hope the recommendations will ensure this tragedy does not happen to another family in the future."
She had begun the therapy in January, after chemotherapy at Yorkhill Hospital in Glasgow. Lisa was 15 when she received repeated overdoses at the Beatson.
The error came to light because the same treatment planner made the same mistake the next time round for a different patient. She had begun the therapy in January.
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 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.
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."
'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
"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.
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.
He said he had learned of Lisa's death during the final stages of preparation for the publication of the report. Health Minister Andy Kerr 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 Andy KerrHealth Minister "Recommendations are aimed at minimising the risk of any possible recurrence."
He expresses his sincere condolences to Lisa's family. The Beatson, which is run by NHS Greater Glasgow and Clyde, has carried out at least 29,000 courses of radiotherapy treatment since 1985.
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. Professor Sir John Arbuthnott, chair of the health board, said: "The treatment of rare and complex cancers will be made safer than ever before.
He said: "It is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly.
"His recommendations are aimed at minimising the risk of any possible recurrence."
The report outlines a number of key safeguards that should be in place to ensure patient safety during radiotherapy.
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 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.""Significant changes have already been made."