Inspection of Scotland's radiotherapy centers will be conducted to ensure that similar incidents like the devastating overdose administered // to teenager Lisa Norris, who died last week, does not happen again, An official report released yesterday stated that Lisa, 16, from Girvan, had become the victim of an error committed during the transcribing of a computer-generated treatment plan at the Beatson oncology center in Glasgow. Therefore in January she was made to undergo 19 separate treatment sessions, that was around 58% higher than the prescribed dose, according to Dr Arthur Johnston, adviser to the Scottish Executive Health Department.

The mistake was made by an inexperienced treatment planner who was unaware of the need of an extra calculation following the installation of a new software system, and then overlooked by a more senior physicist.

The latter, Principal Planner A, has been transferred to other duties that do not involve direct patient care, and the former, Planner B, is undergoing additional supervision and training.

Any further consideration of their future will follow NHS Greater Glasgow's personnel procedures and policies However, on further investigation Dr Johnston found a series of shortcomings at the Beatsond including written procedures and training records for planning the type of treatment required for Lisa were out of date; inadequate staffing for radiotherapy treatment planning; as well as a failure to ensure that the appropriate level of training and experience was brought to bear on planning Lisa's treatment.

Lisa's father, Ken, said: "We are pleased that we have now been told what went wrong. We just hope that the recommendations will ensure that this tragedy does not happen to another family in future."

The results of the post-mortem examination is awaited to find out whether radiation overdoses was the actual cause of Lisa's death.

Andy Kerr, the Health Minister, sai
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