Conclusion.Based on the available information, there is no indication of a malfunction of the mr system or coil used that could have contributed to the incident.The observed reddening and skin damage can be explained by close or direct contact between the patient and the bore wall.No padding was used to prevent this.Contributing factors: the thermoregulation of obese and hypertensive patients is known to be impaired.The risk of rf energy-related injuries is higher in patients with impaired thermoregulation.Several scans with high sar values (>2 w/kg) were executed.High sar scans are a bigger challenge for the cool down mechanism than low sar scans.The total administered specific energy dose of 3.7 kj/kg is very high for a patient with impaired thermoregulation.The instructions for use advises to avoid sed >3.0 kj/kg, preferably keep sed <2.0 kj/kg for those patients.
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