When the Zaragoza Clinic’s electron accelerator malfunctioned and was repaired in early December 1990, it was fortunate that the machine’s annual inspection was due. When the Spanish Nuclear Safety Board carried out tests just before Christmas, it was discovered that the electron beam accelerator control was still malfunctioning, meaning that patients treated for tumors since the equipment was returned to service had received dangerous levels of radioactive overexposure, averaging six times more than the correct dosage. As soon as the error was discovered, the machine was taken out of service, a fortuitous intervention that almost certainly ensured that many lives were saved. But for patients already exposed the damage was done.
Those who had been irradiated suffered skin burns and inflamed internal organs. The first mistreated patient died after just two months and by the time the last unfortunate victim passed away a year later, on Christmas Day, the number of casualties was approaching 20. Nine of those who received a radiation overdose did survive, but all of them suffered from incurable long-term disabilities.
The blame game soon began. Operators using the faulty machine had noticed that when they selected the correct energy level a gauge on the control panel showed the electron beam was at full strength. It was assumed that the gauge had stuck, but in fact a faulty transistor meant the machine could generate a beam only when the maximum amount of electron energy was used. In the end a Spanish court ruled that responsibility rested not with the hospital or its radiological unit, but with the technician who carried out the faulty repair and the American General Electric Company (GE), who supplied the equipment and were responsible for maintenance. It therefore fell to GE to compensate survivors and families of those who died.
When was the Zaragoza Radiotherapy Accident: December 10-20 1990
Where was the Zaragoza Radiotherapy Accident: Zaragoza, Spain
What was the Zaragoza Radiotherapy Accident death toll: 18 (though perhaps up to seven might have died of cancer anyway).
You should know: The machine at the center of this medical scandal was recalibrated and continued in use until 1996, when it was taken out of service and scrapped – very discreetly, to ensure that no adverse publicity was generated to remind the Spanish public of the disaster.
