Top Scots Cancer Centre Fails to Report Dozens of Radiation Blunders



By Paul Thornton

SCOTLAND’S top cancer treatment centre is failing to report dozens of radiation blunders every year – despite guidance by the chief medical officer to do so.

Five serious radiation events at the Beatson West of Scotland Cancer Centre were recorded in the last three years and reported to the Scottish Government while staff faced disciplinary measures.

But bosses at the state of the art facility failed to pass on a further 69 “clinically significant” mix-ups during the same period.

And only one member of staff during that time was reported to the Health Professionals Council or subject to disciplinary procedures over the incidents.

Management at the centre actually admitted that she was only ever reported after deciding to leave – otherwise it too would have been dealt with internally.

However a 2008 paper by Sir Liam Donaldson sees the outgoing Chief Medical Officer call on every major error involving radiotherapy to be logged with the appropriate body.

In his report, Towards Safer Radiotherapy, Sir Donaldson wrote: “Reporting clinically significant radiation incidents to the statutory authority is good clinical governance even if there is no legal requirement to do so.”

The Beatson was previously criticised over the death of teenager Lisa Norris, from Girvan, Ayrshire, who was given 19 radiation overdoses in January 2006 when she received 58 per cent more radiation than she should have.

Managers at the Beatson said they had fully implemented findings of a report on the scandal to make sure such mistakes could not happen.

However an investigation under freedom of information rules has revealed a list of 73 “critical events” occurring in the radiation department in 2007, 2008 and 2009 – with just one passed on to regulators for investigation.

Each case – described as unexpected or unplanned events – is one which could or did lead to unexpected harm to a patient or loss or damage to equipment, and took place across all aspects of radiotherapy.

They include the positioning of patients, the level of treatments and position of doses given as well as clerical and identification mix-ups.

Of those 73 critical events, 70 were described as classification two – or in other words events which have “potential or actual clinical significance” for patients.

Although investigated internally by the Beatson, 69 of them were never passed on to the disciplinary board, the General Medical Council or the Scottish Government.

Last night the new revelations sparked anger from a leading patient group.

Margaret Watt, the chairwoman of the Scottish Patients Association, demanded more openness from the clinic.

She said: “If that is happening then it is totally unacceptable. If mistakes are made then they have to be recorded properly.

“I find it bizarre that there has only been one case reported out of 70.

“It begs the question of what is not being reported and, if there are other cases there and we are not hearing about them, then we should be.”

According to a report in April 2008 by Sir Liam Donaldson, the outgoing Chief Medical Officer, all these events should be reported by management as a matter of course.

In Towards Safer Radiotherapy, Sir Donaldson writes: “Reporting clinically significant radiation incidents to the statutory authority is good clinical governance even if there is no legal requirement to do so.”

Despite this guidance Lesley Cairns – boss of the radiation centre since November 2007 – has only reported one member of staff to a professional body.

The Health Professionals Council is still considering the case against Alison Russell after a horrific mix-up saw a cancer patient given another woman’s radiation dose because staff failed to identify her correctly.

The patient, who has not been named, was suffering from lung cancer but was treated for gullet cancer instead.

And the mistake was only realised when the second patient – who had the same surname – turned up later that day for her treatment.

Russell was demoted over the incident and went on to resign before Cairns reported her to “mark her record” for future employers.

During an earlier hearing of Russell’s case, Cairns admitted that she would not have reported the radiographer’s mistake if she had stayed on.

A decision on Russell’s case will be made in July.

Brain tumour patient Lisa Norris was just 16 years old when she suffered agonising burns and passed away in October 2006.

But the medic responsible for the blunder, Stuart McNee, kept his job to the dismay of Lisa’s family while the centre said it implemented recommendations to safeguard patients in the future.

Asked about the latest FOI findings, NHS Greater Glasgow and Clyde defended the way they measure such events.

A spokesman said: “Robust provisions are in place to ensure prompt notification of all externally reportable incidents to appropriate external regulator.

“Class 2 events are reported internally as part of good clinical governance. A systematic investigation is undertaken for each event.

“The Beatson West of Scotland Cancer Centre diligently adheres to this, and when there has been doubt about whether an incident should be reported to the external authority we have always done so.

“The external authorities responsible for taking reports of incidents are the Scottish Ministers and the Health & Safety Executive NHS Greater Glasgow and Clyde have been commended for their reporting transparency. “

The Scottish Government also backed the centre, saying that the incidents were not considered “significant” enough to be passed on.

A spokeswoman said: “The figures details incidents which are not considered significant enough to be reported under the terms of the procedures for incident reporting.

“There are robust statutory provisions in place for reporting serious incidents to Scottish Ministers as the appropriate regulator, and we expect all health boards to follow these.

“We have no reason to question the diligence with which the Beatson Oncology Centre has reported to Scottish Ministers those incidents that have met the appropriate reporting criteria

“Recording and investigation of less serious incidents is a matter for the NHS Boards’ internal clinical governance and quality assurance provisions.

“However, there is ongoing liaison between the UK Health Protection Agency and radiotherapy professionals in Scotland about provisions for collection of such incident data for national co-ordination and analysis.”