‘Errors made in radiation dosage to man’

Press, 28 April 1981, Page 6

‘Errors made in radiation dosage to man’

PA Dunedin A man who ought to have I received 900 rads of radiation during Cancer treatment at Wakari Hospital received between 3050 and 3150, the Coroner's Court was told yesterday during, the inquest into the death of Desmond Cunningham Dillon, aged 60, of Roxburgh. The coroner, Mr J. M. Conradson, adjourned the case, in which some time was taken up with legal argument about the functions and powers of the court in hearing the case. The hearing will resume this morning. During evidence yesterday, Dr D. H. J. Shine, director of the radiotherapy unit at Wakari Hospital, told the court errors had been made in the radiation dosage Mr Dillon should have received. Radiotherapy was to be given over an unusually wide area to Mr Dillon, which meant a special calculation for dosage had to be made by radiographers and physicists. The calculations should have taken into account treatment given from two fields, the front and the back. In Mr Dillon’s case the calculations were made, but checks after his death showed there was no positive, identification to show these had been checked as normal. Radiotherapy treatment began, but on October 6 Dr Shine ordered it to be stopped because of Mr Dillon’s reaction. Mr Dillon had severe bouts of vomiting and diarrhoea, which Dr Shine could not completely explain in terms of the correct radiation treatment he assumed Mr Dillon had received. Despite treatment and no further radiation, Mr Dillon's condition worsened and he died at 9.45 p.m. on October 10. On October 11 Dr Shine was informed of the death by Dr L. A. Bates, the doctor in

charge of Mr Dillon during his stay in hospital.

“I was rather shocked, horrified, and perplexed,” Dr Shine told the court. “As I couldn't explain his death, nor was it expected, I ordered a post mortem examination.”

After further consultation, Dr Shine examined patient records and identified errors in the radiation dosage given to Mr Dillon. It was decided to ask the Coroner to inquire into the death. Under cross-examination by Dr G. P. Barton, of Wellington, appearing for the family, Dr Shine said Mr Dillon had received 3050 to 3150 rads rather than the 900 he ought to have had at that stage of treatment. Subsequent inquiries showed that two errors had been made in calculating the dose. The physicist had calculated on the basis of one radiation field rather than, two, which meant almost a doubling of radiation.

Further in the calculations a radiographer had made an error which compounded the problem.

The court was told the death led to an internal inquiry by the Otago Hospital Board. The board appointed Dr D. W. Urquhart, president of the New Zealand Cancer Society and head of radiology and radiotherapy at Palmerston North Hospital, to investigate the department’s procedures.

A general audit was made to see how such mistakes could be avoided in the future and changes have already been adopted to tighten procedures for calculating and cross-checking radiation dosages for patients. A pathologist told the court he found that Mr Dillon died of shock and heart failure from severe fluid loss into the bowel, consistent with the effects of radiationinduced necrosis of the small bowel.