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Cancer radiation therapy treatment is performed by delivering a 3D dose distribution to the tumor via the relative rotation between beam and patient. While most modern machines rotate the radiation beam around a still patient, the treatment can also be delivered by rotating the patient relative to a fixed beam. Fixed-beam, patient rotation radiotherapy machines show promise for reducing the size, surface area footprint, and shielding requirements compared with rotating gantry machines. In this Technical Note, we describe the development of a bespoke horizontal patient rotation system for the purposes of a fixed-beam cancer radiotherapy architecture.A horizontal Patient Rotation System was designed in accordance with the appropriate standards pertaining to performance and safety of medical electrical equipment and medical linear accelerators (ISO 9001, IEC 60601-1, IEC 60601-2-1, ISO 14971, ISO 13485, 21CFR820, IEC 62304, Machinery Directive 98/37/EC). The principal criteria for the design were safety, patient comfort, real-time control and the ability to be integrated with other radiation therapy componentry (including a linear accelerator and kV imaging systems).A first of its kind device for securing, immobilizing, translating, and rotating patients has been designed and built and tested against 161 different design, safety, and usability specifications. The device has real-time control for all critical applications.We designed and built a bespoke device which can translate and rotate patients 360° around a horizontal axis. The device meets all design and safety criteria with early usability tests indicating a high degree of comfort and utility. The system has been installed in a clinical bunker, integrated with a fixed-beam linear accelerator and is currently being commissioned for the purposes of cancer radiotherapy treatment.