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Guy's And St Thomas NHS Foundation Trust, Compliance Inspection

  • Site: Transport Competent Authority
  • IR number: 20-035
  • Date: November 2020
  • LC numbers: N/A

Executive summary

ONR regulates the civil transport of radioactive material by road, rail and inland waterway in Great Britain (GB). The ONR Transport Competent Authority (TCA) is responsible for delivering non-nuclear transport inspection and enforcement activities. This particular inspection forms part of that delivery function with reference to Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009 (CDG), the Ionising Radiations Regulations 2017 (IRR17) and the Radiation (Emergency Preparedness and Public Information) Regulations 2019 (REPPIR19). CDG refers to the European Agreement concerning the International Carriage of Dangerous Goods by Road (ADR) and ONR used ADR 2019 during this inspection (www.unece.org).

Purpose of Intervention

The purpose of the inspection was to review Guy’s and St. Thomas’ NHS Foundation Trust arrangements associated with the road transport of radioactive material. ONR carried out this inspection of an emergency exercise at the Old Kent Road Fire Station, Southwark, 405 Old Kent Road site on 25 November 2020, remotely via video link.

Interventions Carried Out by ONR

The chosen inspection sample included:

  • suitable and sufficient measures to restrict exposure – IRR17 Regulation 9;
  • suitable and sufficient Contingency Planning and/or Emergency Arrangements – IRR17 Regulation 13 and CDG 2009 Regulation 24 & Schedule 2;
  • suitable and sufficient emergency planning in accordance with REPPIR19
  • adequate information, instruction and training – IRR17 Regulation 15 and ADR 1.3.1; and
  • a suitable and sufficient Management System – ADR 1.7.3.

Key Findings, Inspector's Opinions and Reasons for Judgements Made

The inspector sampled the arrangements deployed by Guy’s and St. Thomas’ NHS Foundation Trust for the safe transport of radioactive materials, including the associated arrangements for protecting workers against the effects of ionising radiations and reducing risks as low as reasonably practicable (ALARP). 

The inspector compared relevant statutory requirements with both prescribed arrangements and actual practice.  The inspector identified a number of examples of the duty holder meeting relevant good practice in reducing risk to levels that are ALARP, including use of a transport document, marking and labelling of packages, and provision of suitable radiation protection advice to emergency responders. The inspector identified no non-compliances during the inspection.

During the inspection, the inspector also suggested certain improvements to transport practices that would be prudent for Guy’s and St. Thomas’ NHS Foundation Trust to consider.

 Conclusion of Intervention

Guy’s and St. Thomas’ NHS Foundation Trust demonstrated that for certain aspects of its operations it met the requirements of CDG, ADR, IRR17 and REPPIR19. Based on the inspection sample, the inspector identified no non-compliances with relevant legislation and suggested three improvements. The inspector discussed these during the inspection and Guy’s and St. Thomas’ NHS Foundation Trust gave a commitment to address them.

The inspector gave advice on the requirement in CDG that Guy’s and St. Thomas’ NHS Foundation Trust had until 20 January 2021 to provide ONR with a report on the outcome of their test in accordance with the requirements of CDG.

For this intervention, the inspector gave an inspection rating of GREEN, due to there being relevant good practice displayed when compared with relevant benchmarks, compliance with legal duties, and no significant shortfalls identified in the delivery of safety functions.