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.

3. Incident reporting by the ECC

This incident occurred in December 2017, prior to implementation of the new IR(ME) Regulations on the 6th February 2018, but was first reported after that date.

The reporting requirements therefore arise from Regulation 4(5) of the IR(ME) Regulations 2000, which required that: 'Where the employer knows or has reason to believe that an incident has or may have occurred in which a person, while undergoing a medical exposure was, otherwise than as a result of a malfunction or defect in equipment, exposed to ionising radiation to an extent much greater than intended, he shall make an immediate preliminary investigation of the incident and, unless that investigation shows beyond a reasonable doubt that no such overexposure has occurred, he shall forthwith notify the appropriate authority and make or arrange for a detailed investigation of the circumstances of the exposure and an assessment of the dose received.'

The incident investigation and reporting provision arise from the new IR(ME) Regulations 2017, which include a new provision (Regulation 9) that 'The relevant enforcing authority must put in place mechanisms enabling the timely dissemination of information, relevant to radiation protection in respect of medical exposures, regarding lessons learned from significant events'.

With regard to this new provision, this is considered to have been a 'significant event', and this report addresses the resulting duties of the relevant enforcing authority (the Scottish Ministers).

The treatment error was first identified by the ECC on 7th March 2018. The first, notification to the 'appropriate authority' was an e-mail from the ECC to the Warranted Inspector dated 14th March 2018, indicating that an error had been identified and was under investigation. This was followed by an e-mail, from the ECC's Associate Medical Director of Cancer Services dated 12th April 2018, to which was attached a report of the internal incident investigation dated 11th April 2018,

In all senses, it is the view of the inspector that notification was both timely and comprehensive and fully in accordance with the requirements of Regulation 8 of new IR(ME) Regulations 2017 'Employer's duties: accidental or unintended exposure'.


Email: Richard Dimelow

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