Walsall radiographer gave child 50 times recommended radiation during X-ray
A radiographer who subjected a child to 50-times more radiation than recommended during an X-ray had been "rushing", a health watchdog was told.
Camilla Hewitt had worked at the Walsall Healthcare NHS Trust, which runs Walsall Manor Hospital, between June and November 2018 having been employed through RIG Healthcare.
The Health and Care Professions Tribunal Service found there had been three incidents, with one on October 16 involving a child patient who attended for an abdominal X-ray.
An adult radiation exposure was selected for the patient by Ms Hewitt rather than the correct setting, meaning the patient "received an exposure greater than intended" and a second X-ray was performed.
The disciplinary panel noted the patient received radiation approximately 50 times greater than the expected exposure, which prompted a full investigation and a referral to the Care Quality Commission.
A report noted the "low risk" nature of the event was communicated to the patient and an action plan was drawn up with the radiographer – enabling her to produce diagnostic paediatric images, consistently adhering to protocols and adhering to the two-stage process of exposure factor settings.
Ms Hewitt, who completed and signed an incident reflection form, wrote under the heading “Can you identify any Root Causes (Why did it happen?): I didn’t check the exposure factors. I was clear I’d selected the free detector and didn’t need a grid for this patient and didn’t select the paed. option on the drop-down menu. I was rushing as the paed. was wriggling and crying and I wanted to ensure I exposed when they were still."
The original panel heard evidence Ms Hewitt's previous experience at other hospitals was on a slightly different system but the principles of double-checking still applied, the report said.
A second incident occurred on November 20, 2018, when the radiographer again X-rayed a child using an adult setting. The disciplinary panel noted she had administered adult doses of radiation to children, which had the effect of increasing their potential to develop cancer.
The risk of the patients developing cancer in the future was stated to be relatively minimal, the panel said, but added that they were put at risk of harm.
The report found one patient was at risk of harm by having to have the correct ankle X-rayed three times. The registrant’s error in X-raying the left ankle had the potential to cause the injury to the right ankle to have gone undiagnosed.
Three incidents occurred over five weeks and were each described as “fundamental errors of practice”.
The original panel stated that the registrant’s actions were serious and that her conduct fell far below the standards expected of a registered radiographer, in such a way that fellow practitioners would find her conduct deplorable.
The registrant’s contract was terminated by the hospital trust which referred the registrant to the HCPC on November 30, 2018.
