[ RadSafe ] Girl given massive overdose of radiation dies

Mon Oct 23 16:01:01 CDT 2006

Ed,

     Perhaps the following article may shed some additional light on the subject.  Howv er, it doesn't clear up the issue as to if the radiation was X-ray, or gamma.  One might try writing to the author of the story, Mike Waites, mike.waites at ypn.co.uk, to obtain additional information.

  Roy Herren
  ==========================================================
  Row over cancer radiation fears

Yorkshire Post - Oct. 21, 2006 
  Campaigners accuse health chiefs of failing to act on safety warnings after girl's overdose death 

  Mike Waites Health Correspondent 
  CAMPAIGNERS have accused health chiefs of failing to act on safety warnings made two years ago after a Yorkshire cancer patient was given a huge overdose of radiation. 
  The claim follows the death of teenager Lisa Norris on Wednesday, nine months after she was given an overdose of radiation for a brain tumour at a Glasgow hospital. 
  In 2004 an unnamed woman was given two-and-a-half times the recommended level of radiation in 14 treatments at Cookridge Hospital, Leeds. 
  An independent inquiry into the incident made 36 recommendations for change at Cookridge and nationwide - but two years on it is still to be formally published. 
  Hospital chiefs in Leeds say they have implemented the measures but concerns are being raised that the report has had little national impact. 
  Yorkshire former cancer patient Mitzi Blennerhassett, who has carried out an investigation into radiation incidents, said measures could be put in place at little cost. 
  She said priority action included: 
  n Introduction of checks over and above existing safeguards, using detectors to calculate how much radiation patients are receiving; 
  n Setting up national mandatory incident reporting for all hospitals to learn from errors and near misses; 
  n Improved supervision of trainees; 
  n And photographing of patients to prevent mistaken identification. 
  Ms Blennerhassett, of Slingsby, near York, a patient representative on two cancer networks in Yorkshire, said there was "culture of secrecy and failure to learn" from radiotherapy incidents in the health service. 
  She said: "One of the main reasons we are in this position is that there is no one authority dealing with radiotherapy safety. 
  "I'm concerned as much for staff as well as patients because without proper systems and safeguards, without proper support and training, they are at risk too. 
  "They are on the front line waiting for the next accident to happen and because it's becoming more and more complicated the potential for risk is greater." 
  The dean of the Royal College of Radiologists, Michael Williams, said 135,000 courses of radiotherapy were delivered each year in England and Wales and about 24 cases reported of wrong dosages, most of which had no effect on patients. 
  A working party involving experts and patients had been set up by the college, which was due to report next year on the prevention of procedural and human errors as well as effective sharing of information. 
  Doses given to patients were double-checked by staff, but it was clear this did not always work. 
  "We need to look at procedures to make them more effective," Mr Williams said. 
  "We are also disturbed that there is very poor sharing of reports of incidents which means we can't learn from what has happened. 
  "I hope we will see the report into the Glasgow incident published and Leeds will see fit to follow suit." 
  He added: "We can't stop human error but we can stop wrong treatments being delivered and mistakes being repeated." 
  The National Patient Safety Agency said it kept all areas under review but had no plans to prioritise radiation incidents since the numbers were very low and in most cases caused no harm. 
  mike.waites at ypn.co.uk

  Leeds hospital blunder prompted calls for change at national level 

  An independent investigation into the radiation blunder at Cookridge Hospital in Leeds made 36 recommendations for change. 
  The findings had implications for the hospital as well as others across the country and action was recommended at a national level. 
  The Department of Health issued an alert in November 2004 urging hospitals to act on key aspects after concerns were passed on by hospital chiefs. 
  But the report has never been formally published, although an anonymous version is available on request. 
  Campaigners say the full lessons of the incident should be learned by all hospitals providing radiotherapy in Britain. 
  A Leeds Teaching Hospitals NHS Trust spokesman said the report's findings had been implemented in full. 
  More staff were now in place and procedures had been changed, he said. 
  The report found the unnamed cancer patient was given 14 successive overdoses of radiation during her treatment at Cookridge Hospital and at one stage doctors feared it would be fatal. 
  It concluded the incident was caused by "inadvertent human error due to a systems failure". 
  Essentially procedures were in place which allowed a mistake to be made by staff which was not picked up. A system of double checking doses was in place but this had become automatic to staff to the point where it was ineffective. 
  In Leeds, radiographers were often interrupted and distracted while working. It found staff were also overworked owing to large numbers of vacancies and high sickness rates, there was very little continuity between patients and a complex case mix. 
  The report said the National Patient Safety Agency, together with experts in the field, should develop a system to collect and share information about incidents to all those providing radiotherapy. 
  ===========================================================

Ed Stroud <estroud at smtpgate.dphe.state.co.us> wrote:
  Has anyone found additional information related to this incident? I'm trying to find out the source of the radiation (X-ray, gamma?), and what could be done to help prevent recurrence. Very sad. 

Ed Stroud, Health Physicist
Colorado Department of Public Health and Environment

>>> ROY HERREN 10/20/06 1:06 PM >>>
Girl given massive overdose of radiation dies
10/19/2006
By: Reuters Health

LONDON (Reuters), Oct 19 - A schoolgirl cancer patient who was given a massive overdose of radiation has died. Lisa Norris, 16, died at her home in Ayrshire, Scotland, on Wednesday, surrounded by her family. 
In January, she was given 17 overdoses of radiation therapy during treatment for a brain tumor, which left her with severe burns to the back of her neck and head. She had recently undergone treatment to remove fluid from her brain. 
Her father Ken, 51, told the Daily Record newspaper: "She was determined not to give up her fight and she stayed fighting until the end. That's my Lisa. She was our inspiration. She kept us going in many ways." 
Human error has been blamed for the overdoses during treatment at Beatson Oncology Centre in Glasgow but an investigation is continuing. 
Sir John Arbuthnott, chairman of NHS Greater Glasgow and Clyde, which runs Beatson, said in a statement: "This is extremely sad news and I have written to the Norris family to convey my condolences on behalf of the whole organization, especially the staff who cared for her." 
Lisa died after her brain tumor returned, but her father said he was convinced it was the overdoses that "did this, not the cancer", the Daily Record reported. 
The youngster from Girvan was diagnosed with a brain tumor in October last year. 
Last Updated: 2006-10-19 10:01:16 -0400 (Reuters Health)
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Roy Herren

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