Actions in the event of loss or theft, or suspicion of loss or theft, of radioactive material

Version / 4
Name of responsible (ratifying) committee / Medical Radiation Committee
Date ratified / 14 June 2018
Document Manager (job title) / Trust Radiation Protection Adviser
Date issued / 26 June 2018
Review date / 25 June 2020
Electronic location / Management Policies
Related Procedural Documents / Management of Radioactive Materials Policy
Key Words (to aid with searching) / Radioactive material, loss, theft

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
4 / 14/06/2018 / Accounting for new regulation January 2018 / M Daniel
3.1 / 31.03.2017 / 12-month extension to review date. New regulations due February 2018 / -
3.0 / May 2014 / Minor definition changes and review / RPA
2.0 / Jan 2012 / -

CONTENTS

QUICK REFERENCE GUIDE

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

EQUALITY IMPACT SCREENING TOOL

QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural documents.

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

  1. Implementation of procedure in advance of any incident – section 7
  2. Action in the event of loss or theft – check if you are a duty holder or a deputy/nominee – section 3 Scope
  3. Immediate actions for Duty holders – section 5 as applies to your role
  4. Preparation for a routine inspection – section 9 monitoring compliance with, and effectiveness of procedural documents

1.INTRODUCTION

This procedure defines the actions that must be taken in the event that any radioactive material (open, closed/sealed source) is thought or known to be lost or stolen.

2.PURPOSE

Portsmouth Hospitals NHS Trust must discharge a duty of care and compliance with requirements of the permits issued under the Environmental Permitting Regulations that stipulate stringent obligations for the control and management of radioactive materials A failure to meet the requirements of the authorisation, loss or theft representing a very serious failure, is likely to result in prosecution. The Trust must take every possible action to mitigate the consequences of any loss or theft of radioactive materials, and which includes a legal obligation to notify the Environment Agency and other agencies. This procedure sets out those actions and responsibilities.

3.SCOPE

This document applies to;

  • the person discovering any loss or theft of radioactive materials
  • the Radiation Protection Supervisor/Service Manager
  • Clinical Director/Head of Service
  • Trust Source Custodian
  • Trust Radiation Protection Adviser (or nominated RPA)
  • Trust Radioactive Waste Adviser (RWA)
  • Director of Estates
  • Chief Executive’s Office

In the event of any of the responsible persons above not being available, the most appropriate officer shall be identified to undertake the duties identified by that role and who shall provide a detailed brief to the responsible person once available.

In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety.

4.DEFINITIONS

Radioactive Material:

For the purposes of this procedure, any radioactive substance in the form of an open or closed (sealed) source, including a source that is built into a device, being exchanged or held pending disposal.

Permit

Environmental Permitissued by the Environment Agency that sets out minimum conditions that Portsmouth Hospitals is legally obliged to meet for the clinical, scientific or technical use of radioactive materials, and the accumulation and disposal of radioactive waste.

Notification:

Mandatory report to a responsible statutory Agency of an event, non-compliance or breach of terms of apermit) held by the Trust.

5.DUTIES AND RESPONSIBILITIES

In order for the Trust to properly discharge responsibilities in these circumstances, the following duty holders are required to fully discharge the responsibilities as detailed;

Person suspecting or discovering loss or theft of radioactive material:

The person who suspects or knows that radioactive material has been lost or stolen must;

  • Immediately inform the RPS and/or the Service Manager for the department and the Trust RPA or RWA
  • In cases of theft ensure that the affected area is supervised to preserve evidence until the police arrive
  • In cases of loss;
  • undertake an immediate check of records to establish likely location
  • consult with colleagues to check if material has been knowingly moved
  • initiate a quick search to establish if the radioactive material is lost
  • Provide exact details of the radioactive material (nuclide, activity, form, description of container etc.) that will aid recovery should it be found by a third party
  • Check the local rules for any matters relating to the radioactive material in question
  • As soon as possible, make a detailed written report of the incident and provide a copy to the RPS, Service Manager and Trust RPA/RWA
  • Prepare an adverse incident form

Radiation Protection Supervisor (RPS)/Service Manager:

The RPS or Service Manager must:

  • Without introducing any further inappropriate delay, establish with reasonable assurance that the radioactive material has been lost or stolen
  • Make immediate contact with the Trust RPA/RWA or deputy to provide a brief account of the incident.
  • In the case of theft, or attempted theft, of a significant source immediately contact Security, ensure that the facility is supervised to preserve evidence and inform the Trust Source Custodian
  • Establish from the RPA/RWA immediate actions and significance of the incident to the Service, the Trust and any person who may unknowingly come into contact with the radioactive material
  • Inform their Clinical Director/Head of Service
  • Initiate a thorough local search extending to all possible likely locations according to patterns of use
  • Initiate improvements/repairs to ensure security and effective local management of other radioactive materials
  • Provide a point of contact for the investigation of the incident keeping copies of all relevant documents to assist with recovery and review
  • Ensure staff who may have had access to the radioactive material are available if required
  • Ensure that a detailed and comprehensive written report of the incident is made, and follow the Trust’s adverse incident reporting procedure

Clinical Director / Head of Service:

The Clinical Director / Head of Service must:

  • Ensure that the RPS / Service Manager is aware of the actions that need to be taken and to support them in discharging these responsibilities
  • Brief senior managers of the incident, its severity and provide assurance that the incident in being managed
  • In discussion with the Trust RPA/RWA, establish whether the incident constitutes a serious untoward incident and take appropriate action
  • Provide resources to undertake a thorough search to assist recovery
  • Support any investigation carried out by the Environment Agency and where necessary the police or other Agencies (e.g. Health and Safety Executive, Counter Terrorism Security Adviser)
  • Instigate comprehensive improvements to prevent recurrence
  • Ensure procedures are revised where necessary and that any additional staff briefing and training is provided and documented. Ensure the dissemination of learning.
  • Develop an action plan for changes as may emerge following the investigation undertaken by the Trust RPA/RWA or nominee, the Environment Agency or any other body.

Trust Source Custodian:

The Trust Source Custodian will:

  • Liaise with affected staff, the RPS/Service Manager, Trust RPA/RWA and representatives of Agencies to establish sequence of events, details of lost or stolen source
  • Update Trust records to reflect the change in inventory making appropriate entry according to the nature of the loss
  • Provide the Trust RPA/RWA, Director of Estates and RPS/Service Manager copies of source certificates and other information that assist with identifying the source
  • Support the Trust RPA/RWA in preparations for notification and reporting
  • Assist staff, and representatives of Agencies with information and direction in support of searches and investigation
  • Advise on and support immediate action to restore security and management of radioactive materials

Estates manager:

The Estates Manager will:

  • Liaise with the Trust RPA/RWA to establish the need to involve the Police or other security service
  • Liaise with the Trust Source Custodian on local security arrangements and details concerning sources
  • Where the incident involves theft, or attempted theft, to oversee Security for the effective management of the affected facility and staff
  • Ensure prompt improvements are made to the infrastructure to achieve the required integrity of the facility
  • Provide direction and coordination on matters relevant to incident plans
  • Provide every possible assistance to support recovery of any lost radioactive materials
  • Verify adequacy of any changes to security arrangements following the incident
  • Update any Facility support agreements as may be necessary

Trust RPA (nominated RPA) or RWA:

The Trust RPA (nominated RPA) will:

  • Provide immediate advice to the RPS/Service Manager and Clinical Director/Head of Service concerning the risks, implications and immediate actions
  • Advise the Chief Executive’s Office and Risk Management of the incident, consequences, mitigation and details of Agencies as may require notification
  • Provide the Chief Executive’s Office with a document that contains pertinent information for the purposes of the immediate notification), or to make this notification directly where appropriate
  • Instigate an investigation into the incident and thorough review of circumstances, procedures and processes
  • Provide advice to the affected department/service concerning immediate improvements
  • Support any investigation undertaken by the Environment Agency, Police or any other Agency
  • Maintain on behalf of the Trust, a central record of all reports and records relevant to the incident.
  • Provide a report to the Chief Executive’s Office, Risk Management and Governance
  • Provide recommendations to bring about improvements with infrastructure, procedures and processes, and staff training so as to prevent recurrence

Chief Executives Office:

The Chief Executive’s Office will;

  • Consult with and take advice from the Trust RPA/RWA concerning risks, consequences and Agencies to be notified
  • Provide prompt notification to the Environment Agency and other agencies as required
  • Provide an Executive Lead or senior manager to oversee any serious incident involving loss or theft of radioactive material
  • Receive reports from the Trust RPA/RWA and Agencies, instigate and oversee required improvements

6.PROCESS

Immediate action must be taken following and known or suspected loss or theft of radioactive material. Depending on both the circumstances and the significance of the radioactive material, such an event could have serious implications to the Trust.

The Trust is required to make an immediate notification to the Environment Agency and where appropriate, the Police, Health and Safety Executive and other Security Services. Such notifications must only be made directly from the Chief Executive’s office. It is essential that the need for this action is properly verified, provisional details of the event known with some confidence, and mitigating actions implemented without delay. This will be achieved by those with responsibilities identified in Section 5 above effectively discharging the responsibilities as listed.

7.TRAINING REQUIREMENTS

Staff working with radioactive materials must know their duties and responsibilities concerning loss or theft, and be aware of the duties and responsibilities of others. This is to be achieved as part of training and confirmation of competence to undertake this work, which includes the existence of this procedure and how to locate a local copy. This is the responsibility of the Service Manager, supported by the RPS. This is obligatory for all new staff and to be refreshed annually or when there is any material change to local procedures.

All staff working with, and having local responsibility for, radioactive materials must be familiar with the identity of the material and local arrangements for management and security of that material. It should always be possible to know of the location of radioactive materials and hence identify any loss or theft. On no account should staff place themselves or others at risk if they come across any determined attempt to steal radioactive material.

The Radiation Protection Supervisor, Service Manager and Clinical Director/Head of Service will be issued with a copy of this procedure and any additional training support provided by the Trust RPA/RWA as may be required.

8.REFERENCES AND ASSOCIATED DOCUMENTATION

Environmental Permitting Regulations 2016 - Statutory Instruments 2010 No 675 -
Ionising Radiation Regulations 2017. Statutory Instruments 1999 No 1075 –

High Activity Sealed Sources (radioactive) – Management and security arrangements, Portsmouth Hospitals –Available from Trust RPA

9.EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.

Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity

Quality of care

Working together

Efficiency

This policy should be read and implemented with the Trust Values in mind at all times

Loss or Theft of Radioactive Material Policy

Version: 4

Issue Date: 26 June 2018

Review Date: 25 June 2020 (unless requirements change) Page 1 of 11

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure it is effective and to assure compliance.

Minimum requirement to be monitored / Lead / Tool / Frequency of Report of Compliance / Reporting arrangements / Lead(s) for acting on Recommendations
Near misses or lapses in security / RPS/Service manager / DATIX incident reporting / As required / Policy audit report to:
  • Speciality RP group & RWA
/ Service manager with support from RWA

User departments must ensure that staff are aware of the procedure, records attest to that fact, and that the procedure is accessible in a central departmental location with other documentation relating to the use and management of radioactive materials.

In addition, the RPS of user departments will be expected to audit awareness of the requirements annually and in advance of any inspection to be undertaken by the Environment Agency. The Trust Source Custodian will carry out spot checks of awareness and training records within each user department and provide a report to the Medical Radiation Committee.

EQUALITY IMPACT SCREENING TOOL

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments.

Stage 1 - Screening
Title of Procedural Document: Actions in the event of loss or theft, or suspicion of loss or theft, of radioactive material
Date of Assessment / 14 June 2018 / Responsible Department / Medical Physics
Name of person completing assessment / Matthew Daniel / Job Title / Trust Radiation Protection Advisor
Does the policy/function affect one group less or more favourably than another on the basis of :
Yes/No / Comments
  • Age
/ No
  • Disability
/ No
  • Gender reassignment
/ No
  • Pregnancy and Maternity
/ No
  • Race
/ No
  • Sex
/ No
  • Religion or Belief
/ No
  • Sexual Orientation
/ No
  • Marriage and Civil Partnership
/ No
If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2
More Information can be found be following the link below

Stage 2 – Full Impact Assessment
What is the impact / Level of Impact / Mitigating Actions
(what needs to be done to minimise / remove the impact) / Responsible Officer
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document: Specialty Governance Committee
Clinical Service Centre Procedural Document:Clinical Service Centre Governance Committee
Corporate Procedural Document:Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee

Loss or Theft of Radioactive Material Policy

Version: 4

Issue Date: 26 June 2018

Review Date: 25 June 2020 (unless requirements change) Page 1 of 11