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3. Incident reporting by the BOC
3.1 Section 4(5) of the IR(ME) Regulations requires that: ' Where the employer knows or has reason to believe that an incident has or may have occurred in which a person, while undergoing a medical exposure was, otherwise than as a result of a malfunction or defect in equipment, exposed to ionising radiation to an extent much greater than intended, he shall make an immediate preliminary investigation of the incident and, unless that investigation shows beyond a reasonable doubt that no such overexposure has occurred, he shall forthwith notify the appropriate authority and make or arrange for a detailed investigation of the circumstances of the exposure and an assessment of the dose received.'
3.2 In this instance, the 'employer', under the IR(ME) Regulations, is considered to have been the North Glasgow University Hospitals Division of Greater Glasgow Health Board ( GGHB).
3.3 The treatment error was first identified on 1 st February 2006. Details of the incident were reported verbally to the Scottish Executive Health Department ( SEHD) on February 2nd 2006 and this was followed on February 3rd 2006 by a copy of an 'initial report' prepared by a member of staff at the BOC. This report included details of three 'immediate changes' implemented by the BOC in respect of this incident.
3.4 A separate draft report on the incident by Dr Martin, the Head of Health Physics Section*, was provided to the Warranted Inspector on 10 th February 2006 under the title " Preliminary Report of Investigations on Incident Involving Delivery of a Higher Dose than Intended to the Brain During Treatment of the CNS at the Beatson Oncology Centre, Western Infirmary During January 2006". This was followed, on 17 th February 2006, by a formal incident report to the Scottish Ministers (the 'appropriate authority'), again by Dr Martin, under the title " Incident Involving Delivery of a Higher Dose than Intended to the Brain During Treatment of the CNS at the Beatson Oncology Centre, Western Infirmary, Glasgow During January 2006".
3.5 Initial investigations by the BOC confirmed that no other patients had been similarly affected.
* The Health Physics Section has responsibility for advising on radiation protection issues for the whole of Greater Glasgow Health Board.
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