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

Report into the unintended overexposure of a palliative radiotherapy patient in Edinburgh Cancer Centre in December 2017.

2. The format and scope of the investigation and report.

This report records the findings of an incident investigation carried out by Dr Arthur Johnston, 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 Ms Úna Findlay of Public Health England, who provided independent expert advice throughout.

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 ECC and at other radiotherapy centres in Scotland and elsewhere.

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 2018. 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. These have included representatives of the ECC's senior management and clinical staff, including the person referred to as 'Clinical Oncologist B' in this report. Consent to disclosure of information under the Health and Safety at Work Act was obtained from all of those asked.

With particular regard to the provisions of the Data Protection Act 2018, the content of this report has been anonymized to the degree considered necessary by the Inspector to accommodate the consents received from ECC staff. In seeking these consents, staff were advised of the need for job titles to be used in this report to identify individual responsibilities. The particular titles used are, 'Radiographer', and 'Clinical Oncologist'. In addition, to avoid gender identification, the pronouns 'his', 'he' and 'him' and 'himself' are used throughout and are italicised accordingly.

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.


Email: Richard Dimelow

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