Lisa Norris report published
 A report into the death of Lisa Norris - the patient who received overexposure during radiotherapy treatment at the Beatson Oncology Centre, Glasgow - has been met with some concern by the SoR.
"There are questions over the way in which the treatment is planned at this unit as there appears to be little direct input from the therapy radiographers," said Warren Town, director of industrial relations. "We will consider the recommendations and respond accordingly."
The chief investigator, Dr Arthur M Johnston, carried out a detailed investigation into the nature of the error and how it arose. He found that an inexperienced treatment planner had entered the wrong dosage on Lisa's treatment form. Senior staff failed to spot the mistake and Lisa was given 58 per cent more radiation than she had initially been prescribed.
The teenager suffered burns to her scalp and back and later needed surgery to remove fluid from the brain.
Dr Johnston said that the seeds of the tragedy were sown in May 2005 when the Beatson upgraded its computer system to store treatment information electronically. The upgrade, which was intended to improve patient safety and reduce human error, changed the way in which treatment doses were calculated. Beatson, however, retained paper forms for some of the more complex treatments, such as on the spine and the brain. This ultimately led to a treatment planner - referred to in the report as Planner B -making an incorrect entry in Lisa's treatment plan when transferring the data from the computer to paper for the radiographer.
Planner B's error only came to light when colleagues spotted a mistake made in another treatment plan. Dr Johnston said that no other patient had been affected by Planner B's mistakes and emphasised that the error was 'procedural' and not connected to any faults in the computer system.
He acknowledged the potential for his report to add to the concerns of patients undergoing radiotherapy treatment at the centre but stressed that his investigations left him in no doubt of the dedication of the Beatson staff and of their commitment to the safety of patients in their care.
Download the full report PDF
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