[ RadSafe ] The French health ministry has ordered anindependent inquiry into the affair. [SEC=UNCLASSIFIED]

Thu Mar 29 18:23:28 CDT 2007

Ed,

Yes it is the same incident.

There were preliminary reports in October last year which were discussed
on Radsafe and a press release at the time suggested full reports would
be available by the end of 2006.  The recent press surrounding the
incident seems to be the result of the delivery of these more detailed
reports.

I've downloaded the PDF of the IRSN report that Kim McMahan mentioned.
My French is non-existent so I've submitted it to the Google translator
and am now in the process of trying to recast the resulting Franglais
into something that makes sense to me yet hopefully is still true to the
original.  The IRSN report seems to take a much wider aim than simply
the overdoses.  There's also stuff about record-keeping, informed
choice, training and so on.

Peter Thomas
Medical Physics Section
ARPANSA

-----Original Message-----
From: radsafe-bounces at radlab.nl [mailto:radsafe-bounces at radlab.nl] On
Behalf Of Ed Mok
Sent: Friday, 30 March 2007 8:23 AM
To: 'McMahan, Kimberly L.'; radsafe at radlab.nl
Subject: RE: [ RadSafe ] The French health ministry has ordered
anindependentinquiry into the affair.

Is this the same incidents?

http://www.playfuls.com/news_10_17575-Translation-Error-Said-To-Have-Led
-To-
Hospital-Deaths.html

Ed Mok
Stanford Cancer Center

> >-----Original Message-----
> >From: radsafe-bounces at radlab.nl [mailto:radsafe-bounces at radlab.nl] On

> >Behalf Of Jose Julio Rozental
> >Sent: Thursday, March 29, 2007 5:07 AM
> >To: McMahan, Kimberly L.; radsafe at radlab.nl
> >Subject: Re: [ RadSafe ] The French health ministry has ordered an 
> >independentinquiry into the affair.
> >
> >Dear Kim,
> >
> >Thank you for your input,
> >
> >
> >
> >I'll study the site and also I'll ask for more details about - I hope

> >more imputs from colleagues will be arrive meanwhile.
> >
> >Only to inform about doses - I was submitted to radiotherapy to 
> >prostate treatment in Israel, last year, April 2006 - 80 Gy, 40 
> >fraction, 2 Gy per fraction.
> >
> >
> >
> >Jose Julio Rozental
> >
> >joseroze at netvision.net.il
> >
> >Israel
> >
> >
> >
> >----- Original Message -----
> >From: "McMahan, Kimberly L." <mcmahankl at ornl.gov>
> >To: "Jose Julio Rozental" <joseroze at netvision.net.il>; 
> ><radsafe at radlab.nl>
> >Sent: Wednesday, March 28, 2007 10:57 PM
> >Subject: RE: [ RadSafe ] The French health ministry has ordered an 
> >independent inquiry into the affair.
> >
> >
> >> The IRSN investigative report, in French, can be found at:
> >>
> >http://www.irsn.org/document/files/File/Internet/Actualites/synthese_
> >mis
> >> sion_radiotherapie_epinal.pdf
> >>
> >> Unless I mis-read the document (definitely a possibility), the 
> >> software was not the direct cause, and these were not diagnostic 
> >> "scans," they were conformational radiotherapy treatments. 
> >> Treatment planning decisions were made by the medical staff at that

> >> hospital to deliver higher doses in order to control the prostate 
> >> cancers. The typical protocol calls for a dose to the prostate of 
> >> 70-74 Gy, while for these patients the decision was made to deliver

> >> 78 Gy. This higher dose over-exposed the nearby rectal tissue, with

> >> severe consequences. There is some discussion in the report about 
> >> the decision to effectively engage in a clinical trial, and without

> >> informing the patients of increased risks.
> >>
> >> Kim McMAHAN  ORNL External Dosimetry
> >>
> >>
> >> -----Original Message-----
> >> From: radsafe-bounces at radlab.nl [mailto:radsafe-bounces at radlab.nl] 
> >> On Behalf Of Jose Julio Rozental
> >> Sent: Wednesday, March 28, 2007 12:50 PM
> >> To: radsafe at radlab.nl
> >> Subject: [ RadSafe ] The French health ministry has ordered an 
> >> independent inquiry into the affair.
> >>
> >> Dear colleagues, especially from France,
> >>
> >> Who can comment about the subject
> >>
> >> Jose Julio Rozental
> >> joseroze at netvision.net.il
> >> Israel
> >>
> >> One dead, 13 injured in X-ray blunder at French hospital 
> >> http://www.qldcancer.com.au/pdf/November.pdf
> >>
> >> AFP via Yahoo! News - 12-Oct-06
> >>
> >> Agence France-Presse reported that one person died and 13 others 
> >> fell sick after they were exposed to excessive doses of X-rays as 
> >> they were being scanned for prostate cancer at Epinal Hospital near

> >> Strasbourg in eastern France.
> >>
> >> The accidents occurred between May-04 and May-05, where staff 
> >> misused a new software programme that had been installed in the 
> >> X-ray unit. The Lorraine Regional Hospital Agency said that 23 
> >> patients received excessive doses of radiation, and the 13 who fell

> >> ill suffered from rectal inflammation and needed surgery to fit an 
> >> artificial anus.
> >>
> >> The French health ministry has ordered an independent inquiry into 
> >> the affair. _______________________________________________
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> >>
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> >>
> >
> >
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