A Dublin woman died of radiation-induced injuries less than six months after a hospital error led to her receiving a double dosage of radiation treatment, an inquest heard yesterday.
The error has led to a radical overhaul of the checking process at St Luke's and St Anne's Hospital, Rathgar, where she was undergoing treatment for possible secondary tumours, the inquest at Dublin City Coroner's Court was told.
Mrs Mary Guidan (54), of Neilstown Park, Clondalkin, died at St Vincent's Hospital on March 11th last and a post-mortem confirmed that her death was a result of the damage caused to her body by the overdose of radiation.
Prof Donal Hollywood, professor of clinical oncology at St Luke's, said Mrs Guidan was referred to the hospital for radiation treatment following major surgery at the Coombe Women's Hospital on August 25th, 1998, and her treatment began on September 16th. As she was more unwell than was expected while undergoing treatment, a review of her case took place on October 9th and it was discovered that she had been receiving a double dosage of radiation to one of two areas receiving the therapy.
Prof Hollywood said the mistake was due to a transcription error when the planning department was entering the radiation prescription written by a doctor, and approved by the treatment team, into the equipment which delivered the radiation treatment. Two independent checks in the planning section had failed to spot the error and Mrs Guidan had received a double dose of radiation on several days.
He said the double check system had failed and an internal review was carried out immediately. That internal review was followed by an external review by Dr Peter Williams, chief physicist at the Christie Hospital in Manchester. As a result of these reviews new procedures had been put in place.
Ms Michelle Guidan, speaking for herself and her sister Linda, told the inquest the family wanted to ensure that such an error never occurred again. "No one can imagine the pain we have gone through. We will never know whether or not our mother could have been cured, but it is imperative that the hospital learns from this tragedy," she said.
The jury returned a verdict of death by misadventure.