A report into the death of a teenage cancer patient who was given, in error, massive overdoses of radiation to treat a brain tumour, was apparently down to paperwork.
The mistake by an inexperienced health worker led to 16 year old Lisa Norris receiving 19 overdoses of radiation which left her with serious radiation burns and shortly before she died she had undergone treatment to remove fluid from her brain.
Lisa died at home in Ayrshire, Scotland after the tumour returned.
The report commissioned by the Scottish Executive says the overdoses were the result of a single erroneous entry on paperwork setting out her treatment plan at the Beatson Oncology Centre in Glasgow and checks by senior staff failed to spot the mistake.
The report says "significant lessons" need to be learnt and has called for an immediate inspection of all Scotland's five specialist cancer centres.
The father has said he believes the overdoses were responsible for her death but a post-mortem has yet to reveal the cause.
Scotland's Health Minister Andy Kerr says he hopes such mistakes will never be repeated.
The report criticises training records which were out of date, and says written procedures failed to reflect current practice.
Inexperienced staff were also used in the planning of the youngster's treatment.
Lisa's parents have welcomed the outcome of the investigation by Dr. Arthur Johnston.
It appears that the Beatson unit had upgraded the computer system it used to calculate radiation doses in May 2005 but with the most complex treatment plans, data from the system was transferred to paper forms, as happened in Lisa's case.
The "critical error" occurred when the treatment planner transcribed the data from the computer to paper, but and that was not picked up and the incorrect dosing information was passed to the radiographer who gave Lisa her treatment.
The error was only discovered because the same planner made the same mistake the next time for a different patient, but this was identified by a colleague whereby an investigation was launched which found that, apart from Lisa, no other patient had been affected.
Dr. Johnston said the planner had "limited experience" and had been under the supervision of an experienced colleague who failed to pick up the error.
Shortage of senior staff had led to the planner being given a task that he was not experienced enough to do.
The Norris family are now waiting for the results of tests to discover whether it was the radiation overdose or cancer which led to Lisa's death before proceeding with the legal case against the health board.