United Lincolnshire Hospitals NHS Trust was handed a £30,000 fine and ordered to pay £15,128 in costs this week (7 October) after an interventional radiologist was exposed to significant amounts of ionising radiation at a hospital in Boston, Lincolnshire.
Boston Magistrates’ Court heard how an interventional radiologist who was working with a CT scanner at the Pilgrim Hospital in Boston had received more than double the annual dose limit for skin exposure in just over three months.
The radiologist, whose work involved the insertion of biopsy needles into patients, had operated the CT scanner in the continuous ‘fluoroscopy’ mode, which gives ‘real time’ x-ray images. He had observed the process while standing next to the scanner, the court heard.
United Lincolnshire Hospitals NHS Trust had bought the scanner in 2009 and a number of other consultants had used it for the same purpose.
However, the other consultants had used the conventional ‘step and shoot’ method, which required them to leave the room when the CT scanner was generating x-rays.
An HSE investigation found that when the interventional radiologist had arrived at the hospital in August 2011 he had favoured the fluoroscopy mode, which meant operating the x-rays for periods of up to 30 seconds at a time.
In addition, while inserting the biopsy needles, the radiologist had placed his hands directly in the main x-ray beam, which resulted in overexposure of radiation to his hands.
In bringing the prosecution, the HSE found that the NHS trust had never carried out a risk assessment for the CT scanner operating in the fluoroscopy mode, which meant that a safe system of work was not developed.
Its investigation also found that managers were aware that this technique was being carried but did not ensure proper procedures were followed.
At the hearing, United Lincolnshire Hospitals NHS Trust, of Greetwell Road, Lincoln, pleaded guilty to breaching Regulations 7(1) and 11 of the Ionising Radiations Regulations 1999.
Following 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.”
The inspector added that the NHS trust’s failure to assess the risk of the CT scanner operating in a continuous mode had led to the interventionist radiologist being exposed to radiation for far longer and to a much greater extent than should have been allowed.
Speaking to SHP, communications manager at United Lincolnshire Hospitals NHS Trust Clare White, said: “The trust takes any potential safety risks involving our staff very seriously and we fully accept the outcome of the 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. It is important to stress that no patient was exposed to excess radiation.”
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