13].

An underdose may well go on for a much longer period of time and the incident at Stoke [14], when an underdose of approximately 20% continued for several years, serves as a demonstration of this.

At Exeter, there were clinical concerns by the end of May and the beginning of June 1988. On July 4, the calibration of February 12 was still thought to be correct by the Physics Department and it was not re-measured. No further measurement would have taken place until August. The IPEM dosimetry survey [15] measurement, which revealed the error, was done on July 12.

This indicates that it is essential that the staff group responsible for the equipment’s performance must look, measure and check. Measurements can reveal problems much quicker than clinical outcome will reveal them. The difficult decision that needs to be made is what to look at, how to look at it, how often to look at it and how to judge what we find and what to do about it.

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