A mistake by radiographers led to an elderly and disabled cancer patient being given a massive overdose of radiation, a damning investigation has revealed.
Inspectors were called to the Edinburgh Cancer Centre, at the Western General Hospital, after the patient received double the recommended dose of radiotherapy while being given palliative treatment for bone marrow cancer in September last year.
Two radiographers mistakenly calculated the amount of radiation, leading to a dose of 100 per cent the necessary level.
This created “a significant possibility of serious harm” for the unnamed patient, said Dr Arthur M Johnston, a warranted inspector appointed by Scottish Ministers to investigate.
It comes a decade after the high-profile case of 16-year-old Lisa Norris, from Girvan, Ayrshire, who died months after receiving a 58 per cent overdose during treatment for a brain tumour at the Beatson Oncology Centre, in Glasgow.
The patient, whose condition has not been made public, received a more severe overdose than Miss Norris, according to the report.
Dr Johnston said: “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 per cent greater than intended dose of 20 Grays.
“In both instances, the extent of the overexposure was such that there was a significant possibility of serious harm to the patient.”
He said the incident arose due to a “combination of errors made by individuals” operating within the system.
The mistake was only discovered 11 days after the patient’s treatment had ended.
Dr Johnston ordered the centre to uphold a string of recommendations but acknowledged that efforts had already been made to improve the service.
Liberal Democrat health spokesman Alex Cole-Hamilton said: “This is not the first time this has happened in recent memory in Scotland and it is clear that safeguards put in place after the last incident have not worked.”
NHS Lothian has apologised to the family for the “deeply distressing” incident.
Dr David Farquharson, medical director at NHS Lothian, said: “We offered our most sincere apologies to the patient and their family following this very unusual and deeply distressing incident. Since then, we have ensured that they have been kept informed throughout the full and thorough investigation and reporting stages of the process.
“Cases such as these are thankfully very rare, but as soon as it was identified, we implemented a series of measures to minimise the risk of a similar incident. We carried out a robust internal investigation and immediately informed the external inspector.
“In the report the inspector has expressed his confidence in the dedication of the commitment of Edinburgh Cancer Centre staff to the safety of patients in their care and acknowledges the many thousands of life-saving radiotherapy treatments that are successfully prescribed, planned and delivered at the Edinburgh Cancer Centre every year.
“We fully accept the findings of the report and an action team has been created to ensure that each point will be implemented as a matter of urgency, if it has not already been identified during our own investigations.”
A Scottish Government spokesperson 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.”