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.

6. Recommendations arising from the ECC internal investigation, and resulting actions

The recommendations included in the ECC internal report were that:

1. The patient is kept informed throughout the process and is supported. The consultation should include an apology.

2. The relevant oncology team will operate in a culture of openness with both patient and staff involved in this incident with maintenance of dignified confidentiality.

3. The Department continues with regular peer reviews of radical plans and should consider a regular retrospective audit of volumes for palliative treatment.

4. The clinical oncologist involved is supported to mitigate adverse effects of the incident, physical and psychological, both actual and potential.

5. The Directorate should review the palliative work flow and ensure adequate clinical oncologist staffing in the relevant team to minimise unduly busy clinical and planning sessions.

6. The Directorate should consider a named clinical oncologist review of patients for continuity of care by the relevant team.

7. The Directorate should recommend a departmental consideration for more descriptive information on the proposed treatment fields on the radiotherapy booking form, so that if a clinical oncologist finds themselves in a position of planning radiotherapy in a patient they do not know, they have clearer instruction from the referring colleague.

8. The relevant team should also consider regular team building exercises and seek support and help from the Directorate to achieve this.

9. Clinical Oncologist B's IR(ME)R entitlement for more complex plans should be reviewed with an agreed timeline and action plan.

The ECC has advised that as of 31st July 2018, actions arising from Recommendations 1 to 7 had been completed, with the exception of the 'retrospective audit of volumes for palliative treatment' (in Recommendation 3) which is scheduled for completion in November of 2018. Action arising from Recommendations 8 is described as 'ongoing', and action arising from Recommendation 9 is scheduled for completion on 31st December 2018.

With particular regard to Recommendation 5, the ECC has highlighted the difficulties of workforce planning for consultant oncologists in the face of 'severe external constraints', including the need to operate efficiently and flexibly 'at near 100% capacity'.

Actions taken by ECC management in response to these difficulties include detailed management review of individual job plans to ensure, for example, that leave is planned sufficiently in advance to ensure that adequate cover is available,

Having, in accordance with Recommendation 5, reviewed 'the work flow and adequate consultant staffing', the ECC has concluded that with regard to their principal aim of 'the safe and effective provision of patient centred care', 'NHS Lothian Cancer Services provides a safe and efficient clinical service through the continuing pressures of increasing demands and services at full capacity'.


Email: Richard Dimelow

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