Unintended overexposure of a patient during palliative radiotherapy treatment: investigation report

8. Conclusions and recommendations.

8.1 The causes of the error

The findings of this investigation lead to a conclusion that staffing pressures contributed to this error.

In particular sickness absence of a colleague meant that Clinical Oncologist B was the only team member available on a particularly busy Friday, this being the last day before the Christmas break, when there was pressure to 'tie up loose ends'.

However, it is apparent also that inconsistences in the levels of staffing for clinical oncologists (in this case lack of staff on Fridays) and the functioning of the specialist teams are problematical throughout the year.

The ECC has acknowledged these difficulties, but has advised that a staffing review has been completed and the staffing levels are considered by the ECC to be 'adequate'.

While this might indeed by the case, it is clear that problems remain, as identified in Section 5.3.1 of this report.

With regard to the duties of the employer under the IR(ME) Regulations, this investigation has concluded that the lack of appropriate documentation of training prior to entitlement of Clinical Oncologist B as an operator within the ECC constitutes a failure on the employer to comply with the relevant provision of the IR(ME) Regulations for training and entitlement of duty holders.

Concerns about the maintenance of Employer's Written Procedures and Protocols, have also been identified.

Neither of these concerns with regard to the duties of the employer is considered to have been a contributory factor in this error.

8.2 Recommendations for further action by the ECC

In addition to the actions recommended in the ECC internal report (Section 6 of this report) the following corrective actions are recommended:

Documentation relating to training of staff prior to entitlement should be reviewed with a view to ensuring that the training required prior to entitlement for each particular competence is clearly documented and that there is clear definition of how such successful completion of such training must be recorded (preferably by completion of an authorised pro-forma).

Pro-forma training plans should include details of the training that must be completed, and should include provision for identification of the person undergoing the training, the person confirming satisfactory completion of that element of the training, and the date on which this is done.

An inclusive review of the working practices of all ECC clinical oncology teams should be undertaken with the aims of identifying and addressing weekly inconsistences in staff provision and any other deficiencies in palliative radiotherapy working practices and processes that might contribute to errors.

The current 'team based' approach to patient care should be reviewed with due consideration of replacement of this approach with an 'individual named clinical oncologist' approach (whereby patient care is assigned to an individual member of each team rather than to the team as a whole).

Current provisions for document control should be re-examined in the light of those provisions that are in place in other areas of Lothian NHS Board.