Page last updated at 11:41 GMT, Monday, 8 March 2010

In full: Statement on Lisa Norris FAI

Lesley Thomson, area procurator fiscal for Glasgow and Strathkelvin, invited Glasgow Sheriff Court to make a formal determination in terms of Section 6 of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976.

It reads as follows - 6(a) that Lisa Jayne Norris died on 18 October 2006 at 16 Downhill Road, Girvan, Ayrshire; (b) that the cause of death was recurrent pineoblastoma.

Here is her statement in full.


"I am seeking a formal determination at today's FAI hearing. I do not propose to lead any evidence and I present to your Lordship the post mortem report in respect of Lisa Jayne Norris.

"I can advise that steps have been taken to stand down witnesses cited to give evidence and to alert parties' representatives in advance of this morning's hearing of the Crown' position as set out in this statement.

"I understand that all parties are content with the Crown's approach today.

"The background and reason for my submission today is as follows:

"In late July 2005 Lisa Jayne Norris (born 7 April 1990 - then aged 15) contacted NHS 24 and thereafter her GP with complaints of abdominal pain, vomiting, fever and headaches.

"From late July until mid August Lisa attended her GP, was referred to the paediatric Department of Ayr Hospital and then admitted to Ayr Hospital on 17 August and transferred to the Southern General Hospital on 18 August.

"At that time following a biopsy she was diagnosed as having pineoblastoma.

"Lisa's treatment for this cancer was a combination of chemotherapy and radiotherapy. She received chemotherapy at the Sick Children's Hospital Yorkhill and the radiotherapy at the Beatson West of Scotland Cancer Centre.

"It has been established and accepted by all parties that she received an accidental overdose of radiotherapy treatment at the Beatson between 5 January 2006 and 31 January 2006.

"This error was discovered on 31 January 2006. An investigation into the circumstances of that error was carried out by Dr Arthur Johnston, Inspector appointed by the Scottish Ministers.

"Lisa died on 18 October 2006 and the circumstances of her death including the cause of her death and the cause of the accidental overdose were investigated by the Crown including the instruction of medical experts.

"At the same time these causes were investigated by representatives for Lisa's parents and by Greater Glasgow Health Board.

"It is of course my duty as the Procurator Fiscal to enquire into certain categories of deaths including the accidental and unexplained to establish exact causal links and to allay any public anxiety and concern.

"Thereafter I report the results of my enquiries to Crown Counsel.

"I did that in this case and a Fatal Accident Inquiry was instructed by the Lord Advocate in order to establish the cause of death and whether or not there was any causal link with the radiation overdose.

"During the investigations by parties there were differing medical views expressed by experts and that continued until very recently. One expert thought there was a link between the accidental overdose of radiation therapy and Lisa's death.

"However, by mid-February 2010 as a result of further detailed enquiries and discussions with experts it was established and agreed that this was not the case and that no such link could be substantiated.

"The medical experts who are all in full possession of the facts and the initial differing opinions have ultimately concluded that there is no causal link between the radiation overdose and Lisa's death.

"At the second preliminary hearing on 22 February 2010 the representatives for Lisa's family indicated to your Lordship that the family accepted that there was no causal link between the accidental overdose and her death.

"In light of the statements made to the court by the representatives of the family and Greater Glasgow Health Board that further consideration be given to the holding of a Fatal Accident Inquiry at which evidence would be led I considered I should review the circumstances.

"Shortly after the continued preliminary hearing on 22 February the representatives of Lisa's family advised me that the family had reached the view that they were content that a full investigation had been carried out, that there was no causal link between the radiation overdose and Lisa's death and that they did not want the Fatal Accident Inquiry and the leading of evidence now to take place.

"They also accepted that the Beatson since the date of the radiation overdose error had taken steps to rectify the problem by reviewing their systems and had improved and replaced them to seek to ensure that such an error could not occur again.

"Following the representations therefore by the family and the Greater Glasgow Health Board it is clear that there no longer exists any controversy surrounding the cause of Lisa's death and the cause of Lisa's tragic death is clear.

"The decision to hold the Fatal Accident Inquiry at public expense has been reviewed.

"There is a continuing duty on the Crown to review the need for a Fatal Accident Inquiry in light of materially changed circumstances and if, as in this case, there are no matters of dispute that require to be aired in public it is not appropriate to cause any further anxiety and distress to the bereaved relatives by the hearing of evidence - nor the incurring of expenses by any of the parties' representatives or indeed the cost of the FAI much of which would fall on the public purse.

"However, in saying that I do need to make it absolutely clear that the decision was not taken on the grounds of costs but on the issues of causation and the steps taken by the Beatson to address the radiation overdose error.

"In all the circumstances therefore and in view of the following facts:

• that there is now no dispute about the accidental radiation overdose error

• the constructive steps taken since by the Beatson to review and improve systems

• and the cause of Lisa's death having been established and agreed

the circumstances have been reviewed and the Crown is now seeking a formal determination in terms of Section 6 of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976 as follows:-

6(a) that Lisa Jayne Norris died on 18 October 2006 at 16 Dowhill Road, Girvan, Ayrshire;

(b) that the cause of death was recurrent pineoblastoma.

"May I conclude by offering my condolences to Lisa's parents and family for their tragic loss, a loss which they have borne throughout with great dignity."



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Critical error: The Lisa Norris story
10 Jun 07 |  Scotland

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