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Beatsond including written procedures and training records for planning the type of treatment required for Lisa were out of date; inadequate staffing for radiotherapy treatment planning; as well as a failure to ensure that the appropriate level of training and experience was brought to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, said: "I am shocked and disappointed at what has happened. Part of that shock is that the Beatson is such a big part of the cancer service. It is an important job and we do it well. Yet we have this single catastrophic event.
"We have had in the past significant staffing problems but we have made significant investment in doctors, nurses, support and technical staff, and we are training more."
Sympathizing with the Norris family, he said: "My impression of Lisa Norris was of a dignified, brave and determined young woman."
He said that around 12,000 life-saving radiotherapy treatments a year took place in Scotland, of which nearly 5000 were at the Beatson.
Since the catastrophic event recommendations that have already been implemented include: new procedures to ensure that the dose lies within the expected range; simplifying the procedure for specifying the amount of radiation to be given; an extension of their triple checking system and improvements to quality system and documentation; individual training plans for all members of staff.