Continuing Sunday Express investigations into the radiation over-exposure incident at the private facility which is owned by powerful business interests reveal that the board and management of BLCTC failed internationally accepted guidelines on several critical fronts, specifically:
1. Its decision to ignore a PAHO (Pan American World Health Organization) issued TLD (thermoluminescent dosimeters) warning of a suspected 14 per cent overdose in April 2009. The privately owned Medcorp facility ignored strict, internationally accepted, safety standards to resolve the dose discrepancy identified in the mailed TLD audit.
2. Its decision to bury and then deny (when the report was made public) the June 2010 finding of a US-certified senior medical physicist of a calibration error ranging from four to 20 per cent of a linear accelerator used for clinical radiotherapy.
3. Its decision to continue treating cancer patients during and after the Damian Rudder discovery of a radiation overdose and
4. Its failure to immediately notify the licensing authority, the Ministry of Health, and affected patients and their families of the potential threat of radiation injury to their long-term health and well-being.
The radiation incident at BLCTC has been shrouded in secrecy from the outset. Neither the State nor the centre involved has given a full account about what happened or the severity of the radiation injuries suffered by patients or even the number of patients who have since died. Sources with knowledge of the situation told the Sunday Express that 91 of the affected 223 patients have died in the period that ended January 23, 2012, the date that the IAEA mission arrived in Trinidad.
According to the IAEA (International Atomic Energy Agency) Basic Safety Standards (BSS) 1996 protocol, the Brian Lara Treatment Centre broke a significant number of best practice rules. Several of the affected patients including families of those who have died told the Sunday Express they were never contacted by anyone or medically assessed for late radiation side effects, a clear contravention of accepted best practice and BSS convention.
Most of the affected patients say there is a lot they don’t know about the incident and that what information they have was gleaned from media reports. The IAEA’s protocol for transparent and mandatory reporting of radiotherapy accidents was not observed by either the private radiotherapy provider or the Ministry of Health. The State licensing authority which is duty bound to protect patients and ensure the well-being of the general public not only failed to immediately investigate the incident but continued to refer patients from the public sector to BLCTC at a guaranteed cost to the State of US$8,000 per patient. More than 60 per cent of the 223 were State referrals paid for with taxpayers dollars.
It took three months and an adverse press report before the Ministry of Health even acknowledged there was a problem, again in contravention of IAEA safety standards, which was established for the worldwide protection of health, life and property against ionising radiation.
After years of saying it is something this country wants to sign up for, Trinidad and Tobago is still not an IAEA member State and is not bound by international convention to comply with the safety protocols issued by the world’s leading nuclear authority.
From all accounts, the licensing authority’s response to the radiation incident was one of virtual inertia. According to e-mails obtained by the Sunday Express, the then chief medical officer (CMO) Dr Anton Cumberbatch took his time to respond to calls for urgent state action to protect cancer patients who were being overdosed. One e-mail, sent by the centre’s former radiation oncologist Dr Anesa Ahamad on June 29, 2010 (19 days after the Rudder discovery of an overdose) noted this: “On Friday June 18, I spoke to you on an urgent matter. It remains urgent.”
Describing the situation as “most unusual and distressing”, the Ahamad e-mail referenced her conversation of June 18 with the CMO and concerns she raised with the Medcorp Board and management. The e-mail noted in part: “I advised that all patients on treatment must have their biologically effective doses already received calculated, as this is higher than prescribed. Patients need to be informed. This relates to patients on treatment. I also advised that all patients treated over the period from spring 2009 to present be called in, informed, counselled, supported, compensated etc and damages paid for. This is the right thing to do.”
Ahamad, who separated under less-than-amicable terms from BLCTC, said she was told by the covering oncologist at the private facility that he had received no information save that it was “safe to treat”.
The e-mail correspondence to Cumberbatch noted that the board of BLCTC had barred her from entering the facility and that junior physicists and staff had been gagged by confidentiality agreements to not discuss any of the events.
She pointed to the absence of radiation legislation and made clear that the Ministry of Health was responsible for licensing all private institutions. In an apparent desperate bid to get state intervention for patients, Ahamad said: “I went to you in person as the CMO and related my concerns verbally. I am unable to confirm what action has been taken. Patients are being harmed as we speak. You are the only one with the authority to act.”
The e-mail further noted: “I am not sure what else I can do at this point, and thus my e-mail to you. I am very concerned for patients. Please note that I am giving you my full support. Please note that overdose of radiation causes severe late effects—and although records can be buried—patients side effects will be pretty obvious and any radiation oncologist examining a patient will be able to say confidently that this is consistent with an overdose.”
She warned: “If patients are being continued to be overdosed (since no adjustment on doses being given was done) anyone who failed to act will have to accept responsibility.”
She ended the e-mail by saying: “I have been instructed not to discuss this matter with the public.”
Ahamad wrote CMO Cumberbatch again on July 16, 2010, repeating her earlier offer to help and expressing concern for patients. She also warned that the Ministry would be subject to embarrassment if ever the matter was made public. She advised that there were protocols to deal with radiation incidents and that the protocol she was obliged to follow was to inform the CMO. She ended on this note: “I am already being contacted by doctors with patients who have severe bleeding, etc which I cannot explain by the dose that was prescribed.”
On August 31, 2010, Cumberbatch announced that the Ministry of Health had approached PAHO for help.
Even after PAHO and more recently, the IAEA, found evidence of severe radiation injury among a sample population of the affected patients, the private cancer centre continues to maintain that no mistakes were made. Minister of Health Dr Fuad Khan also played the scientific language game, grasping a point made by the IAEA mission about the difficulty “at this time to clearly and unequivocally state that the observed injuries in the assessed patients were in fact caused by over-radiation”.
He and BLCTC’s lead defenders choose to ignore the summary finding of the IAEA mission, which noted that: “The radiotherapy speciality of medicine, like most specialities, does not have the precise science and statistics that we might wish for and sometimes clinical experience must ‘weigh in.’ That being said, some of these patients had clinical evidence of such severe radiation injury that an experienced clinician cannot help but think that an approximate 15 per cent overdose may have been a contributing factor in causing an increased severity of the injuries in some of these patients.”
IAEA press spokesman Giovanni Verlini last week made clear that the mission to Port of Spain was not an investigation but a medical assessment for a patient group selected by the government of Trinidad and Tobago.
“The objectives of the mission,” Verlini said, “were established according to the request of the GOTT. The group of patients who were examined was established by the Ministry of Health in Trinidad and Tobago.”
He said the mission was designed to provide assistance to the Ministry of Health “and is in no way intended as a tool designed to replace a national function”.
He said: “A comprehensive assessment of the cases of over-exposure at the BLCTC goes beyond our mandate.”
He said questions relating to the limited scope of the IAEA enquiry and who should pay for the follow-up medical care needed by the overdosed patients were better put to local authorities.
Minister Khan said he is looking into the issue of who should pay.
The BLCTC has denied all liability and refused to pay costs for follow up medical care needed by the overdosed patients.