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2. The format and scope of the investigation and report
2.1 This report records the findings of an incident investigation carried out by Dr Arthur Johnston, Scientific Adviser to the Scottish Executive Health Department ( SEHD), as the Inspector warranted by the Scottish Ministers, in accordance with the provisions of the IR(ME) Regulations, for the functions described in Sections 19, 20 and 21 of the Health and Safety at Work Act 1974. The investigation was supported by officials from the Scottish Executive Health Department, and Mr Steve Ebdon-Jackson and Ms Carol Nix of the UK Health Protection Agency provided independent expert advice throughout.
2.2 The scope of the investigation and of this report extends beyond consideration of compliance with the statutory provisions of the IR(ME) Regulations to more detailed assessment of the circumstances that caused this incident and of the measures that should be enacted to minimize the potential for adverse incidents at the BOC and at other radiotherapy centres in Scotland and elsewhere.
2.3 Information obtained by the Inspector during the course of this investigation is subject to restrictions on disclosure, particularly those pertaining to Section 28(7) of the Health and Safety at Work Act 1974. Reporting of any information that might be regarded as personal data is further restricted under the provisions of the Data Protection Act of 1998. To address the issues arising from this legislation, the relevant consents were sought from those who provided information and from those for whom it was intended that personal data be included in this report. Consent to disclosure of information under the Health and Safety at Work Act was obtained from all of those asked.
2.4 With particular regard to the provisions of the Data Protection Act 1998, the content of this report has been anonymized to the degree considered necessary by the Inspector to accommodate the consents received by BOC staff. Further consideration of anonymity has been necessary to enable BOC staff to consent to disclosure of information provided. In seeking these consents, staff were advised of the need for the titles used in this report to identify individual responsibilities. In general, therefore, individuals are referred to by a title that conveys their relative seniority. The particular titles used for treatment planning staff are, in order of decreasing seniority, 'Principal Planner', 'Senior Planner' and 'Planner'. These titles are not intended to correspond with actual job titles or gradings used at the BOC or in other UK radiotherapy departments. In addition, to avoid gender identification, the pronouns ' his', ' he' and ' him' and ' himself' are used throughout and are italicised accordingly.
2.5 It is the view of the Inspector that the requirement for anonymity of the staff involved and the decision of some members of BOC staff to withhold consent to the inclusion of personal data has not detracted significantly from the principal aims of the report which are those stated in Paragraph 2.2.
2.6 Regarding the possibility of legal action arising from this incident, the regulatory powers of the Inspector appointed by the enforcing authority (the Scottish Ministers) extend to issuing of Improvement Notices and Prohibitions Notices under the provisions of Sections 21 and 22 of the Health and Safety at Work Act 1974. Any consideration of additional legal proceedings in Scotland is a matter for the Crown Office and Procurator Fiscal Service and is not within the scope of this report.
2.7 This report makes frequent reference to the computer systems used at the BOC for treatment planning. Particular reference is made to Varis 7, Eclipse and RTChart (registered trade marks). In this regard, it should be noted that at no point in the investigation was it deemed necessary to discuss the incident with the suppliers of this equipment since there was no suggestion that these products contributed to the error.
2.8 Staff at the BOC have requested specifically that any Report should again convey to Lisa's family their deep regret for this incident and for the distress that they have suffered as a result.
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