Scottish Government

ISBN 0 7559 6297 4
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Contents

Covering Letter
Executive summary
1 Subject
2 The format and scope of the investigation and report
3 Incident reporting by the BOC

4 Incident description
4.1 Referral
4.2 Treatment Planning for patient Lisa Norris
4.2.1 General treatment planning provisions
4.2.2 Spine fields
4.2.3 Head fields
4.3 Treatment Delivery

5. Investigation of the circumstances of the incident
5.1 Summary of the initial investigation
5.2 Why was the wrong 'Output' figure entered?
on the Medulla Planning Form?
5.2.1 The effect of changes to treatment
planning procedures in May 2005
5.2.2 The role of Planner B in planning this treatment
5.2.3 The role of the Principal and Senior Planners in
planning this treatment
5.3 Why was the wrong 'Output' figure on the Medulla Planning Form
not identified in checking?
5.4 5.4 A missed opportunity to identify the potential for error
from another plan

6. Consideration of background circumstances at the BOC
6.1 Introduction
6.2 Staffing pressures and workloads
6.2.1 Staffing levels in Scotland
6.2.2 Staffing provisions for treatment planning at the BOC
6.2.3 Staffing provisions for the treatment plan for Miss Norris
6.2.4 The effect of staffing pressures on the general integrity
of the treatment planning system at the BOC
6.2.5 How deficient were the BOC's staffing levels
for Treatment Planning?
6.3 Individual responsibilities
6.4 Compliance with IR(ME)R procedures

7. Consideration of the findings of a previous investigation into the conduct of Isocentric Radiotherapy at the North Staffordshire Royal Infirmary between 1982 and 1991
7.1 Introduction
7.2 The causes of the North Staffordshire incident
7.3 Findings of the Baldwin Report relevant to the BOC incident
7.4 7.4 Recommendations of the Baldwin Report relevant
to the BOC incident

8. Summary of principal findings

9. Actions and recommendations
9.1 Introduction
9.2 Actions already taken by the BOC
9.3 Additional actions recommended by the Head of Health Physics
9.4 Further recommendations arising from this investigation
9.4.1 Recommendations for action to be taken by the BOC
9.4.2 Recommendations for action by other parties
9.5 Further actions under the IR(ME) Regulations

10 Concluding remarks
10.1 Introduction
10.2 Levels of responsibility for treatment planning staff.
10.3 Levels of responsibility for BOC and GGHB management
10.4 Lessons arising from this incident

11 Acknowledgements

12 References

Annex 1: BOC quality system document number WI.14.01.01, written procedures for 'Medulla Planning'
Annex 2: A blank copy of the first page of Medulla Planning FM.14.014 as used for Lisa Norris's treatment plan
Annex 3: BOC quality system document number WI 13.26.06, written procedures for 'Medulloblastoma Calculations'
Annex 4: A copy of the Inspector's note of the incident investigation meeting held on 10 ^th February 2006
Annex 5: Staff interviews
Annex 6: Staffing levels in the BOC Treatment Planning Section at December 2005
Annex 7: Comment on compliance with those requirements of the IR(ME) Regulations that were of particular relevance to this incident