I'm sure most have you have seen the news about the poor young Scots girl of 15 with a brain tumour who has been given 17 times the radiation dose due to human error.

Have any of you felt as low as I have about this today. Firstly just seeing the young girl so burnt and how she was suffering so badly and knowing noone can do much to ease her discomfort.

Then recalling the days of our own weeks of radiotherapy and how painful and uncomfortable it was for ourselves and that was hopefully with the correct dosage. The whole thing of seeing her blisters breaking down has made me feel unusually low. Is anyone else feeling like this.

I agree Pauline - it's tragic for the girl and her family. Not only has this this young girl got a brain tumour (which is in itself seriously distressing for her and her family) she has to contend with the fact she has received 17 ADDITIONAL! treatments of RT.
How could this mistake be made!! - it is UNBELIEVABLE! but it has happened.
I am not surprised at the negative effect it has had on you.
I keep thinking of Mo Mowlam who had RT on a brain tumour about 8/9 years ago. When Mo died last year, God rest her soul, it was as a result of the effects of RT and not as a result of any tumour.
SO the effects of any excess RT on such a sensitive organ can only be imagined. And it's a horrible thought. I hope her health authority will give her the support and help she and her family deserve.

Tony

It is awful for this young girl with her life ahead of her. You are correct too that just having a brain tumour is bad enough without the extra stress. But when she said she felt hot inside I think some of us knew that feeling from the cooked tongue bit and being unbale to quench that heat.

Last year there were articles in the paper about Hiroshima and Nagasaki survivors of World War 2. When I think of radiotherapy and the dose those people suffered yet survived to the present day, despite being at the centre of the radioactivty, I conclude that some people have a better genetic constitution. Look how some people don't feel affected by the treatment compared to others.

Maybe this girl will get lucky with youth on her side. Let's pray so.

I know that I was told it was better to have rads treatment when you were as fit and as healthy as possible rather than waiting until you were ailing very badly and weak. 17 times the correct dose does seem an awful lot more. I think we could all see the human error more easily if it was ten times more dosage and a decimal point error. But this semms an unusual miscalculation.

I think every person who has radiotherapy now will be questioning the dosage. You know just like when you have anaesthetic and quip before going under please give me enough oxygen.

This is not the first time I have heard of this type of error. Recently a friend of my sisters was told she had been given too much on just one occasion. When that radiotherapist realised the error she ran out of the room crying.

Was it the same for others here, but when I was treated, at least two people always checked each other at the measuring aligning stage with the mask and on then on the computer monitor before the rads pulse.

For this girl the 17 times as much dosage sounds as if the error has been made in the planning stages to me.

Hi Pauline

These mistakes are very distressing to the patient, the therapist and the public. Human fallibilty has always occurred. I hope that an investagation will reveal how it happened and steps taken to tighten and improve safeguards to avoid this happening again.

quote:

James Reason was a Professor of Psychology at Manchester University who studied human error and who proposed the so-called Swiss Cheese model of accidents. Each defensive layer in the system has a number of holes in it (like a slice of Swiss cheese) that represent vulnerabilities. These holes are not static (ie they are not in the same position all of the time) and, when they happen to line up then an accident trajectory has been created.

Holes are not static for several reasons. They may represent individual human actions - so a human error will be represented as a hole in this model. They may represent procedural failings that may only arise under certain environmental circumstances (e.g. when the team of people involved in carrying out a procedure is under-strength). They may represent transient software faults that are corrected automatically when the system state is recomputed.

Sadly, it may be impossible to guarantee that this sort of thing never ever happens again. We can only reduce the chances of it happening.

Best wishes
Vinod

Hi Pauline - I think this girl is so brave going "public" and she has raised the public's awareness of what radiotherapy entails for many of us.
BTW I don't think the girl had 17 times the corect dose of RT but she had 17 ADDITIONAL doses of RT. Given that most of us seem to have 20 or 30/35 doses depending on the strength of each dose I think this girl has probably had ,maybe, 50% approx more than what she should have. I still can't for the life of me understand how this was done.

Tony

My apologies re the dosage - I must have heard it incorrectly when I first caught it on the radio. Thanks for pointing it out.

You are correct that people may have seen the burning now for the very first time. I know until I researched rads before my treatment I had little idea of what radiotherapy would really entail other than the myth it was painless. I was disgusted when I read a breast cancer article and a woman with it said radiotherpay was a doddle compared to chemo. Maybe it is for breast cancer but not so for the head. By that time I was on something like day 10 and really feeling all the effects and it made me so angry that is why I continued to record my online diary just as I had been about to stop writing it.

You are told you feel nothing when radiotherapy happens and I suppose you do feel nothing except terror whent they all leave the room and slam a great big lead door on you. I disagree with the you don't feel anything as I always felt a strangeness when the bursts were given. But as you knwo it's nothing really painful only strange until of course it takes effect and I know for me it took effect day 1.


I think I do believe like Vinod that out of tragedy a move forward happens. No doubt this will create a new safety protocol.

The reporting both in the press and the radio of this story has been somewhat ambiguous. I am not even sure if my statement concerning the dosage is absolutely correct.

This really does show how little is known by "the outside world" concerning this type of treatment. One would have thought the press/radio/news would have researched the facts and reported them more clearly than they did. Still they're not ones to let the facts get in the way of a "good" story.

Radiotherapy affected me so much mentally and physically as I'm sure it did (and still does)for you and many others.

To be honest it's a kick in the nether regions when the reporting of such news cannot be better explained. In the transient world of news reporting this story is history. For those of us that suffer from the effects of RT it's ongoing for the rest of our lives.

Tony

Do you think we will ever learn of the percentage extra doasgae this girl had?

Today on TV news I just caught a snatch of a specialist professor suggesting Hyperbaric treament to help her.

He also implied that some burning would occur with any radiotherapy as if the news team and public just don't realise this. i think he's right even without overdosage I don't think the general public understand that you get very very red and blistered by the time you have had 18 - 20 treatments and much worse 30 or more usual dosage treatments.

I do hope they can help her and hope too that the mistake is a starting point for new check procedures at hospitals that have minimal calibration checking.