 Lisa Norris was given overdoses during radiation therapy |
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.
She died last week at her home in Ayrshire, nine months after a dose of radiation 58% higher than prescribed.
Her father Ken, 51, from Girvan, said: "We are pleased we have now been told what went wrong."
Immediate inspections of Scotland's five cancer radiotherapy centres will take place in the wake of the report.
 |  It is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly |
Mr Norris added: "We just hope the recommendations will ensure this tragedy does not happen to another family in the future."
Lisa was 15 when she received repeated overdoses at the Beatson.
She had begun the therapy in January.
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.
He said: "A change was made to a system of working without adequate analysis of the possible consequences for patient safety.
| READ THE REPORT
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"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."
Dr Johnston concluded most of the responsibility and "hence any blame" could be attributed to the principal planner.
Health Minister Andy Kerr said: "It is clear to me that more work is needed to ensure outstanding issues are tackled quickly and thoroughly.
"Recommendations are aimed at minimising the risk of any possible recurrence."
The Beatson, which is run by NHS Greater Glasgow and Clyde, has carried out at least 29,000 courses of radiotherapy treatment since 1985.
Professor Sir John Arbuthnott, chair of the health board, said: "The treatment of rare and complex cancers will be made safer than ever before.
"Significant changes have already been made."
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