Office for Nuclear Regulation

University Hospital Plymouth NHS Trust compliance inspection

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 undertaking non-nuclear transport inspection and enforcement activities.  This particular inspection forms part of that function with reference to Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009 (CDG) and the Ionising Radiations Regulations 2017 (IRR17).  CDG refers to the European Agreement concerning the International Carriage of Dangerous Goods by Road (ADR) and ADR 2019 was used during this inspection (

Purpose of Intervention

The purpose of the inspection was to review University Hospital Plymouth NHS Trust (UHPNT) arrangements associated with the road transport of radioactive material.  ONR carried out this inspection remotely via Microsoft Teams on 28 October 2020.

Interventions Carried Out by ONR

The inspector sampled the following arrangements deployed by UHPNT 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):

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

During the inspection, the inspector sampled UHPNT’s prescribed arrangements and compared them with the relevant statutory requirements and associated relevant good practice (RPG).  

The inspector identified examples where UHPNT’s arrangements have met ONRs expectations, including Local Rules, certain parts of its written management system arrangement such as clear and well-presented flow charts and the various annexes that contained checklists for emergency kits and inspections of package before dispatch.  Several non-compliances were identified during this inspection, which included some aspects of the management system and an incomplete RRA, which meant that it was not possible to determine whether an emergency plan or contingency plan was required.

Various improvements to UHPNT’s arrangements were discussed that would be prudent for it to consider.

Conclusion of Intervention

Based on the sample inspected and the associated evidence gathered before and during this intervention, UHPNT has demonstrated that some of its arrangements meet the requirements of CDG, ADR and IRR17. 

The inspector identified 2 areas of non-compliance with relevant legislation and suggested 4 minor improvements.  These were discussed with UHPNT during the inspection along with a commitment to address them.

UHPNT was given until 11 December 2020 to provide ONR either with evidence that the findings have been resolved, or an appropriate resolution plan with timescales for completion.  

As a result, ONR has rated this inspection as GREEN.