Scottish Government

Covering letter

Unintended overexposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre,Glasgow in January 2006

Covering note

It was during the final stages of preparation for the publication of this report that I received the tragic news of the death of Miss Lisa Norris. Like people across Scotland, I had followed reports of her progress and shared the widespread admiration of the courage and dignity that she showed. 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.

One of the main purposes of my report is to make recommendations aimed at lessening the risk of any similar incident at the Beatson Oncology Centre in Glasgow and elsewhere. It is important, therefore, that the report is available for general distribution and I wish to express my thanks to Lisa's family for their co-operation in allowing this to happen.

The report is the result of a detailed investigation into the nature of the error and how it arose. 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. By the time that the error was identified Miss Norris had received 19 out of the prescribed 20 treatment fractions. The total dose of radiation received was therefore some 58% higher than the dose prescribed.

The general intent of the recommendations arising from this report is to raise awareness of the need for the maintenance and implementation of quality working systems in all areas where patient safety is of concern. Heavy commitments to other areas of work can often deflect attention from this need but it is precisely in these circumstances that the risk for error is greatest and appropriate management intervention is most crucial.

I am conscious of the potential for the content of this report to add to the concerns of those undergoing radiotherapy treatments at the Beatson Oncology Centre. In this regard 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. It would be remiss of me not to acknowledge the many thousands of life-saving radiotherapy treatments that are successfully prescribed, planned and delivered at the Beatson Oncology Centre and, indeed, at the other radiotherapy centres in Scotland every year. Proper attention to the lessons learned from this incident and to the recommendations contained in the report will further enhance the safety of these treatments.

I would urge all of those working in the health services to ensure that the lessons that can be learned from this incident help in ensuring that future risks to patient safety are significantly lessened.

Dr Arthur M Johnston
Warranted Inspector appointed by the Scottish Ministers