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Last Updated: Sunday, 10 June 2007, 11:28 GMT 12:28 UK
Critical error: The Lisa Norris story

By Samantha Poling
BBC Frontline Scotland

Frontline

When news broke in February 2006 that teenager Lisa Norris had received a massive overdose of radiation whilst undergoing treatment for brain cancer at the Beatson Oncology Unit in Glasgow, the shock was felt far beyond Girvan, the small Ayrshire town where she lived.

Lisa died eight months later - the cause of her death was given as cancer. But her parents have never accepted this, believing the radiation overdose killed their daughter.

Frontline decided to look into Lisa's radiation overdose and investigate how common this kind of mistake is.

Lisa Norris received a massive overdose of radiation

I also wanted to examine whether Lisa might have died because the NHS had failed to learn critical lessons from previous mistakes in the delivery of radiotherapy.

And I discovered that there are now wider questions about the delivery of radiotherapy treatment in Britain.

Cancer affects people of all ages: one in three adults in Britain will suffer from cancer during their lives. Of those, half will undergo radiotherapy.

The treatment was pioneered at the start of the 20th century and involves directing high-energy x-rays at a tumour to kill cancerous cells.

It is usually successful but it is a delicate process. Too much radiation and healthy cells will die along with cancerous ones.

Too little radiation and the cancer will grow. Patients receive doses of radiotherapy according to an individual treatment plan.

Reddened and blistered

But Lisa's plan was wrongly transcribed- a simple, but disastrous mistake meaning that on the 19 occasions she received the treatment she believed would save her life, she was in fact suffering a dangerous overdose.

She received 58% more radiation than intended.

Lisa suffered terribly. Ken and Liz Norris watched helplessly as their daughter's skin reddened and blistered.

Even a cold shower could not soothe the pain: "When the water hit her head it just evaporated", said Ken, "as if you had put water in a hot pan, you could see it going to bubbles."

I then discovered that Lisa's Norris' overdose was not an isolated mistake.

Sarah Macdonald's husband James had also been treated at the Beatson.

He received radiotherapy on the left side of his neck to remove a tumour in 2004. His dose was correct. Unfortunately the tumour was on the other side of his neck. James died in 2005. The official cause - cancer.

CANCER TREATMENT
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And the mistakes were not confined to Scotland. Ten years ago, Daryl Williams of Cumbria received all of his radiation in two weeks instead of four- double the intended dose.

Daryl lost the ability to read and write, as well as movement on his right side.

The Christie Hospital in Manchester, where he was treated, accepts the mistake, but does not ascribe Daryl's current problems to the overdose.

Daryl has spent the last decade rebuilding his life.

So how are these elementary mistakes made? Frontline saw an unpublished report into an incident at the Cookridge Hospital in Leeds. Its author was Professor Brian Toft, an expert in risk analysis.

He discovered radiotherapy planners at Cookridge were working in highly pressurised conditions and consequently, routine checking procedures were compromised.

Planners must check that the dosages are correct and correspondent to the patient's plan. But Professor Toft found they were so rushed that on occasions few checks were carried out before treatment began.

He told me: "I've called it ambiguous accountability. Supposing the patient calls, somebody makes a cough, a noise, and I look away and you look away at the same time. Who exactly is carrying out that check?"

Radiotherapy
One in three people will be affected by cancer in our lifetimes

The answer in the case of Lisa, Daryl, and James, would appear to be "no-one".

Other cancer experts believe poor working conditions are not all that is wrong with radiotherapy in Britain.

Professor Karol Sikora, former head of the cancer treatment at the World Health Organisation, believes there are wider problems.

He states that some patients are being given radiation over too short a time period in order to save resources, and to meet waiting times.

He told me: "The knock-on effect is that they are cured of their cancer - and many patients will be cured by radiotherapy- but they're going to have long-term side-effects they wouldn't have had if they'd had a much more prolonged course of radiotherapy."

Radiotherapy treatment

And Professor Sikora believes that the radiation overdose could have contributed to Lisa Norris's death.

He said: "My understanding of the case was that probably, on the balance of probability, she wouldn't have died if she had received the correct dose of radiotherapy."

In Ayrshire, Lisa's parents remain convinced that a critical error in radiotherapy treatment killed their daughter.

"What they've done is unforgivable and we will fight on," said Ken Norris.

"It doesn't matter if it takes 10 years we will still be going with it."

Critical error: The Lisa Norris story will be broadcast on BBC One Scotland at 1900 BST on Monday 11 June.


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