ABSTRACT
Introduction In January 2006, LN (then 15 years old) was a patient at the Beatson Oncology Centre (BOC)1 in Glasgow, Scotland. While undergoing a series of doses of radiation therapy for a relatively rare and complex brain tumour, it was discovered that the 17 dose fractions received by LN were some 58% higher than prescribed. This has become known as the Beatson Event. LN died in October 2006. It has been a matter of some contention whether she died as a result of the overdose or the underlying cancer, though from the perspective of this paper this is not an issue. What is the issue is the background to the event, the response by the authorities in investigating and reporting the event, and how the perspective of resilience engineering would view things.
