United Lincolnshire Hospitals NHS Trust which runs Pilgrim Hospital has been fined £30,000 after an interventional radiologist was exposed to significant amounts of ionizing radiation.
Boston Magistrates’ Court heard today that the male staff member working with a CT scanner at the Boston hospital received more than double the annual dose limit for skin exposure in just over three months.
As an interventional radiologist his work involved the insertion of biopsy needles into patients, which he carried out using the CT scanner operating in continuous ‘fluoroscopy’ mode, giving ‘real time’ x-ray images which he observed while standing next to the scanner.
The scanner, which the trust bought in 2009, was used by a number of other consultants for the same purpose but they used the conventional ‘step and shoot’ method which required them to leave the room when the CT scanner was generating x-rays.
However, when the interventional radiologist arrived at the hospital in August 2011 he favoured the fluoroscopy mode, operating the x-rays for periods of up to 30 seconds at a time. Moreover, whilst inserting the biopsy needles he placed his hands directly in the main x-ray beam, resulting in an overexposure of radiation to his hands.
An investigation by the Health and Safety Executive (HSE) found that the trust had never carried out a risk assessment for the CT scanner operating in the fluoroscopy mode so a safe system of work was not developed.
In addition, managers were aware that this technique was being carried out but did not ensure proper procedures were followed.
United Lincolnshire Hospitals NHS Trust (ULHT) pleaded guilty to breaching Regulations 7(1) and 11of the Ionising Radiations Regulations 1999 and was fined a total of £30,000 and ordered to pay costs of £15,128.
Speaking after the hearing, HSE inspector Judith McNulty-Green said: “The regulations require exposures to ionising radiation to be kept as low as is reasonably practicable.
“In addition there are dose limits which should never be exceeded. In this case the dose to the radiologist’s hands was twice the relevant legal dose limit.”
A spokesman for ULHT said: “The trust takes any potential safety risks involving our staff very seriously and we fully accept the outcome of today’s proceedings. We are confident that this was an isolated incident and have implemented a series of measures to ensure that it is not repeated.
“These include reviewing working practices for all staff working with ionising radiation, and further developing checklists for all areas radiologists work in to provide a more comprehensive training record.”
They added: “t is important to stress that no patient was exposed to excess radiation.”
“As United Lincolnshire Hospitals NHS trust failed to assess the risk of this machine operating in continuous mode it led to the interventional radiologist and patients being exposed to radiation for far longer and to a much greater extent than should have been allowed.”