We are testing a new beta website for gov.scot go to new site

wrapper

Unintended overexposure of a patient during radiotherapy treatment at the Edinburgh Cancer Centre, in September 2015

Unintended overexposure of a patient during radiotherapy treatment at the Edinburgh Cancer Centre, in September 2015

Friday, July 8, 2016

ISBN: 9781786523525

The report of a detailed investigation of an incident involving a serious overexposure to ionising radiation for a patient undergoing radiotherapy, in September 2015.

Executive Summary

Between 14th September 2015 and 18th September 2015, a patient received a dose of ionising radiation much greater than that intended while undergoing a course of radiotherapy at the Edinburgh Cancer Centre (ECC) in Scotland.

This report, by the Inspector warranted by the Scottish Ministers for the IR(ME) Regulations, records the findings of the incident investigation. It identifies the errors that caused this overexposure and includes consideration of the deficiencies that contributed to the errors and where responsibilities for these deficiencies lay. It also makes recommendations intended to minimize the possibility of recurrence of any similar errors and to enhance patient safety in radiotherapy more generally.