Three radiographers who admitted zapping a patient
Three radiographers who admitted zapping a patient’s foot with 10 times too much radiation were cleared of ‘infamous conduct’ at a medical inquiry today.
(Tues)
The dose caused the unfortunate patient pain and is likely to affect his longterm health.
The blunder came after a doctor at St George’s Hospital, near Lincoln, made a prescription error.
Dr Thiagarajan Sreenivasar advised that the un-named man, suffering from benign fasciitis in his foot, should be exposed to 45 units – ten times more than he was meant to get.
The hearing was told such a dose was only normally given to people with cancer and ‘reduced life expectancy.
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Dr Sreenivasar, a consultant clinical oncologist, had missed out a decimal point and intended just a tenth of that dose.
No action was taken against the doctor by the GMC but giving evidence he told the Council for Professions Supplementary to Medicine in Kennington, southeast London: ‘It must have been a busy day.
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Radiologists Elizabeth Gascoyne, 40, Helen Clewer, 46, Simon Smith, 37, had been charged with ‘infamous conduct’ for failing to spot the doctor’s mistake.
But the Council found the trio not guilty of ‘infamous conduct in a professional respect’ over the overdose which left the victim with radiation burns to his foot.
Chairman Sandy Yule said: ‘The facts have been admitted and suggest the respondents may have fallen
below the standard expected of state registered radiographers.
‘We have taken into account that at the time in question the department appeared not to have in place adequate procedures and protocols.
‘The committee has taken in account all that has been put before it including that this was an isolated incident in otherwise unblemished careers, that the respondents have all recognised their failures in this matter and that lessons have been learnt.
‘The respondents have all continued to have exemplary records following these events.
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Christopher Donnison, defending all three radiographers, said the system was to blame for the blunder.
Mr Donnison said: ‘The dosage was given by a very respected oncologist.
‘The dose had been written quite clearly.
Unusually it had been written three times the third with the quite deliberate intention of emphasising the
dose that was required.
‘The radiographers followed the only protocol in effect at the time.
That arrangement was quite ineffective to prevent this overprescription being
given to the patient.
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Mr Donnison said Gascoyne was unaware the patient’s condition was benign until halfway through the treatment on July 26, 1999.
‘Smith didn’t know about the problem at all, again a problem which has been remedied since.
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Clewer knew the condition was benign but she thought the consultant had increased the dose after earlier radiotherapy treatment had failed, Mr Donnison added.
Since the incident steps had been taken at St George’s Hospital to prevent similar mix-ups.
The fact Dr Sreenivasar was not disciplined by the GMC was also important for the committee to bear in mind.
‘I appreciate the GMC is a different body, but given that, by any standard he was more culpable than the people before you today, I ask you to take that decision into account in your deliberations,’ added Mr Donnison.
Gascoyne was working on a six week temporary appointment at the time of the incidents.
She is now working in a hospital in Hull.
Smith and Clewer both still work at St Georges.
Gascoyne of (19) Laceby Road, Grimsby, South Humberside, admitted: two charges of failing to question a prescription of radiotherapy in respect of a patient; and two charges of being involved in the exposure of a incorrect dosage of radiotherapy to a patient.
Smith, of (13) Troutbeck Close, Beckside Village, Lincoln, and Clewer, of (12) Nursery Avenue, Farndon, Newark, Notts, both admitted: one charge of failing to question a prescription of radiotherapy and one charge of being involved in the exposure of an incorrect dosage of radiotherapy.
But they each denied infamous conduct.
ends
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