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Gloucestershire Hospitals Trust (Cheltenham General hospital) Transport - Inspection ID: 53738

Executive summary

Date(s) of inspection: 

August 2025

Aim of inspection

The purpose of the inspection was to review compliance of the Cheltenham General Hospital (CGH) arrangements for class 7 radioactive material for road transport, covering consignee, consignor and carrier duties. 

Subject(s) of inspection

  • Transport - Carrier Duties - Rating: GREEN
  • Transport - Consignee Duties - Rating: GREEN
  • Transport - Consignor Duties - Rating: AMBER
  • Transport - Dangerous Goods Safety Advice - Rating: GREEN
  • Transport - Emergency/Contingency Planning and Testing - Rating: AMBER
  • Transport - Management Systems - Rating: GREEN
  • Transport - Package Maintenance and Operation - Rating: GREEN
  • Transport - Radiation Protection Advisor - Rating: GREEN
  • Transport - Radiation Protection Programme - Rating: GREEN
  • Transport - Radiation Risk Assessment - Rating: AMBER
  • Transport - Security - Rating: GREEN
  • Transport - Training and Competence - Rating: GREEN
  • Transport - Vehicle equipment and Placarding/Markings - Rating: GREEN

Key findings, inspector's opinions and reasons for judgement made

The inspector reviewed a range of topics and identified a number of examples of CGH meeting relevant good practice, in reducing risk to levels that are ALARP and demonstrating compliance with IRR17 and CDG09, including appropriate IRR17 consent, appointment of Safety Advisers (Radiation Protection Advisers and a Dangerous Goods Safety Adviser), training of Radiation Protection Supervisors and Trust drivers, package labelling, marking of contractor vehicles and security arrangements.  

 

The inspector identified three areas of non-compliance and discussed these during the inspection. These were associated with transport radiation risk assessments, emergency arrangements and demonstration of package compliance with ADR requirements.

Conclusion

The inspection findings were presented to CGH at the close of the inspection.
 

I judged an overall inspection rating of 'Amber - Seek Improvement' was appropriate for this inspection as as there were deficient arrangements for compliance with legal requirements.

 

CGH is required to provide ONR either with evidence that the three identified non-compliances have been resolved, or an appropriate resolution plan with timescales for completion, by 30 September 2025. The non-compliances will be tracked to completion via a level 3 regulatory issue.
 

As CGH is part of Gloucestershire Hospitals NHS Foundation Trust, the findings of this inspection should be applied to all transport activities undertaken by the trust.

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