Patient given double radiation dose in error at Edinburgh Cancer Centre
It happened in September 2015.
A cancer patient was mistakenly given double the dose of radiation required for their treatment, a new report has revealed.
Two radiographers at the Edinburgh Cancer Centre both incorrectly calculated the amount of radiation to be given when the patient was being treated for multiple myeloma - a type of bone marrow cancer.
The patient, who has not been identified, was prescribed radiotherapy as part of their palliative care. But a report for Scottish ministers said the dose received was 100% greater than the intended dose''.
It comes 10 years after teenager Lisa Norris, from Girvan in South Ayrshire, was given an overdose of radiation whilst undergoing treatment for brain cancer at the Beatson Oncology Unit in Glasgow and subsequently died.
In the report, Dr Arthur M Johnston, the warranted inspector appointed by Scottish ministers, said the overdose of radiation given to the patient at the Edinburgh centre in September 2015 was more severe.
He stated: It is approximately 10 years since I was last called upon to undertake a detailed investigation of an incident involving a serious overexposure to ionising radiation for a patient undergoing radiotherapy.
That earlier investigation was the overexposure of Miss Lisa Norris at the Beatson Oncology Centre in Glasgow, who was being treated for a pineoblastoma, from which, tragically, she subsequently died at the age of only 16.''
While Miss Norris received radiation amounting to 58% greater than the intended dose'', Dr Morris:In this case, the treatment delivered at the Edinburgh Cancer Centre (ECC) was a palliative radiotherapy treatment for alleviation of pain and existing disability in an older patient, and the dose received was 100% greater than intended dose.''
He added: In both instances, the extent of the overexposure was such that there was a significant possibility of serious harm to the patient.''
A Scottish Government spokeswoman said: We extend our thoughts and sympathies to the patient and their family, who have been affected by this incident.
While these incidents are extremely rare, it can be very serious if any patient is overexposed to radiation and so it is right that procedures at the Edinburgh Cancer Centre were fully, and independently, investigated.
NHS Lothian and the Edinburgh Cancer Centre have taken a number of steps to change practice and minimise the risk of an incident like this happening again.
We expect the health board to take forward all of the recommendations in the report and progress will be monitored closely by the inspector.''