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

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

10 Actions already taken by the ECC

Treatment planning for this patient was started, but not completed, during the weekend 'on-call' period. Internal consideration of the circumstances of this incident has therefore led the ECC to review on-call staffing provisions and relevant on-call procedures. This has led to a number of changes including strengthening of on-call staffing, changes to on-call procedures, and the introduction of an additional calculation check for patients who commence their radiotherapy treatment during an on-call period.

The ECC has also undertaken a review of current practice in accordance with the 'Self Assessment Tool' in 'Towards Safer Radiotherapy'[2]


Back to top