LONDON (Reuters), Oct 27 - A teenage cancer patient was mistakenly given massive overdoses of radiation for a brain tumor, mainly because of a mistake in paperwork, a report found on Friday.
Lisa Norris, 16, died at her home in Ayrshire, Scotland, last week, after battling the tumor for a year.
Speaking of the overdoses, the report said "the principal cause of this incident was identified as a single erroneous entry" on paperwork setting out her treatment plan at Beatson Oncology Centre in Glasgow.
Checks by senior staff also failed to spot the mistake.
The report, commissioned by the Scottish Executive, said "significant lessons" needed to be learned.
Norris suffered serious radiation burns as a result of the overdoses. She died after the brain tumor returned, but her father has said he is convinced it was the overdoses that were responsible. A postmortem has yet to report.
The inquiry report called for an immediate inspection of all Scotland's five specialist cancer centers.
"I hope today's report will help to ensure that the mistakes made in her treatment are not repeated," Scotland's Health Minister Andy Kerr said in a statement.
In January, Norris was given 19 overdoses of radiation therapy and shortly before she died she had undergone treatment to remove fluid from her brain.
Among criticisms in the report were that training records were out of date, written procedures failed to reflect current practice and inexperienced staff were used in the planning of the youngster's treatment.
Last Updated: 2006-10-27 10:37:42 -0400 (Reuters Health)
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