a problem in dosimetry software caused an overdosage during radiotherapy. During this period 7500 patients were treated for prostate cancer at the Jean Monnet Hospital in Epinal, France. An investigation showed that 5 people died from radiation, 24 were severely injured, 700 were significantly overexposed, and 4500 were mildly exposed. March 11, 2006 – at Fleurus, Belgium, an operator working for Sterigenics, at a medical equipment sterilization site, entered the irradiation room and remained there for 20 seconds. The room contained a source of 60Co which was not immersed in the pool of water. Three weeks later, the worker suffered symptoms typical of acute radiation syndrome (vomiting, loss of hair, fatigue). One estimate that he was exposed to a dose of between 4.4 and 4.8 Gy due to a malfunction of the control-command hydraulic system maintaining the radioactive source in the pool. The operator spent over one month in a specialized hospital before going back home. To protect workers, the federal nuclear control agency AFCN and private auditors from AVN recommended Sterigenics to install a redundant system of security. It is an accident of level 4 on the INES scale. Teenager Lisa Norris died in 2006 after she was given an overdose of radiation as a result of human error. The overdose occurred during treatment for a brain tumor at Beatson Oncology Centre, in Glasgow, Scotland. The Scottish Government published an independent investigation of this case. The intended treatment for Norris was 35 Gy to be delivered by a linac machine to the whole of the central nervous system to be delivered in twenty equal fractions of 1.75 Gy, which was to be followed by 19.8 Gy to be delivered to the tumor only (in eleven fractions of 1.8 Gy). In the first phase of the treatment a 58% overdose occurred, and Norris's CNS suffered a dose of 55.5 Gy. The second phase of the treatment was abandoned on medical advice, and Norris survived for some time after the overdose. January 23, 2008 – A licensed radiology technologist, Raven Knickerbocker, at Mad River Community Hospital in Arcata, California performed 151 CT scan slices on a single 3 mm level on the head of a 23-month-old child over a 65-minute period. The child suffered radiation burns (skin erythema) to a small strip of his face and head. In one report, an independent investigation of the child's blood was said to have