Date: 5 January-1 February 2006
Location: Glasgow, Scotland, United Kingdom
Type of event: radiation therapy overexposure
A 15-year-old female patient was receiving radiation therapy for a tumor at Beatson Oncology Centre in Glasgow. She was given 17 treatments over a period of time with the first on 5 January. As a result of human error, all 17 treatments were far in excess of the prescribed dose (one report states the doses were 65% too high). The error was not identified until after all treatments were administered, shortly before the patient was informed on 1 February. Symptoms as of early February 2006 included large sores on the scalp and ears and permanently higher than normal body temperature. The total dose was reported as potentially fatal; the localized dose to the brain and neck posed a risk of brain damage, paralysis, or death through damage to blood vessels in nerve tissue. The patient's condition, including damage to the eyes, had improved by late February in response to hyperbaric treatment. On 19 October the patient died (then aged 16); she had been recovering from surgery in September to remove fluid from her brain. An investigation into the cause of the accident was reportedly in its final stages as of October. Subsequently her death was attributed by health officials to her cancer. Reports indicate that 39 other patients at Beatson had received overdoses during radiotherapy between 1985 and 2006, most with no adverse results.
Consequences: 1 death.
© 2006, 2007 by Wm. Robert Johnston.
Last modified 16 September 2007.
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