My knowledge of the Scottish legal system is fairly limited (ok, non-existant), but it looks like the sad case of Lisa Norris, a 16 year old girl who died in 2006 after receiving a radiation dose 58% greater than prescribed, is under investigation yet again. A fatal accident inquiry has just been launched looking into the circumstances of her death. An earlier investigation by the government of Scotland found that a staff member at the Beatson Oncology Center in Glasgow was under-trained and under-qualified, and that the staff member made a critical error on a form that led to the wrong dose being delivered. However, an autopsy determined that Lisa died from complications of her pineal cancer and not from the overdose.
Lisa’s parents still maintain, however, that the overdose led to her death and have apparently convinced the Scottish government to reopen the case. I’m not familiar with what a fatal accident inquiry entails, but here is a passage from the Wikipedia article.
Generally the Procurator Fiscal will receive notification of a person’s death and will investigate any which appear suspicious or where investigation is mandatory regardless of the suspicion of crime. Where the death appears to be due to a criminal act the Procurator Fiscal will initiate investigations by the police or other appropriate public authorities to enable the identification of suspects and associated evidence to enable him to prosecute the case in the Sheriff Court or for an Advocate Depute to prosecute in the High Court of Justiciary. However, if the circumstances give rise to investigation, or if the death occurred while the deceased was in lawful custody the Fiscal may choose to examine matters in greater detail. Where the circumstances justify it in the public interest, or where there is a statutory requirement the Fiscal will intimate his intention to prepare evidence for a Fatal Accident Inquiry.
If I am reading this correctly, it appears as if the inquiry could end in criminal charges being filed against the health care workers responsible.
Criminal charges for medical errors in radiation therapy are not unprecedented. Two medical physicists in Panama were sentenced to four years in prison after an error in treatment planning software overdosed 28 people, killing at least 18 of them. Also in Costa Rica, a physicist was sentenced to six years in prison after miscalibrating a Cobalt-60 unit, killing 30 people and injuring 59.
In this case, I believe criminal charges would be a gross overreaction. Leaving aside the question of whether Lisa died from her cancer or the overdose, the error occurred at a clinic that was woefully understaffed and under-equipped for the patient load they were expected to treat. According to this article from 2006, 5000 patients a year were given radiation treatments at the Beatson Oncology Clinic. That is an incredibly busy center. It accounted for almost half of all of the radiation treatments in Scotland. At the same time, a report from the Scottish government stated,
207. Using current recommendations from IPEM (Institute of Physics and Engineering in Medicine) an establishment of 58.5 WTE radiotherapy physicists is required for Scotland. The current establishment is 42.5 WTE, a shortfall of 16 WTE posts. Also 8 WTE posts were vacant as at December 2004 and therefore only 34.5 WTE were in post, less than 60% of the recommended level.
The final report on Lisa’s death acknowledged the role that understaffing played in the error.
When a horrible incident like this occurs, the first instinct is to find out who is to blame. In this instance, I believe that the blame lies in a system strained to the breaking point. Given that workload, it was only a matter of time before a grave error was made. Holding people criminally accountable who were only trying to do an impossible job would send a chilling note throughout the radiation therapy community. Needless to say, many will be watching the outcome of this inquiry, myself included.
