Executive summary
Date(s) of inspection: August 2024
Aim of inspection
The purpose of the inspection was to review compliance of the Queen Elizabeth Hospital (QEH) arrangements for class 7 radioactive material for road transport, covering consignor and consignee duties.
QEH is part of the Lewisham and Greenwich NHS Trust and the inspection findings should be applied to all hospitals within the trust.
Subject(s) of inspection
- Transport - Consignee Duties - Rating: Green
- Transport - Consignor Duties - Rating: Green
- Transport - Dangerous Goods Safety Advice - Rating: Green
- Transport - Emergency/Contingency Planning and Testing - Rating: Amber
- Transport - Management Systems - Rating: Green
- Transport - Radiation Protection Advisor - Rating: Green
- Transport - Radiation Protection Programme - Rating: Green
- Transport - Radiation Risk Assessment - Rating: Amber
- Transport - Training and Competence - Rating: Not rated
Key findings, inspector's opinions and reasons for judgement made
The inspector reviewed a range of topics and identified a number of examples of QEH meeting relevant good practice in reducing risk to levels that are ALARP, including appropriate appointment of a Radiation Protection Adviser, transport documents, transport package certification and package labelling.
The inspector identified 2 areas of non-compliance and discussed these during the inspection. These were associated with the Radiation Risk Assessment for transport and emergency arrangements.
Conclusion
The inspection findings were presented to QEH at the close of the inspection.
I judged an overall inspection rating of 'Green- No formal action' was appropriate for this inspection as as there were no significant shortfalls identified in the delivery of safety.
QEH is required to provide ONR evidence that the 2 identified non-compliances have been resolved by 27 September 2024. The non-compliances will be tracked to completion via a level 4 regulatory issue.