Introduction and Purpose

The Trust’s Policy for Radiation Protection is in accordance with the general Health and Safety Policy. The aim is to ensure the safety of staff, patients and public. The policy covers the use of ionising radiation in the diagnostic and interventional radiology departments at Ashford (AH) and St Peter’s Hospital’s (SPH), the nuclear medicine department and other areas. It requires the use of radiation to be properly justified, doses to be kept as low as reasonably practicable (ALARP) and relevant dose limits adopted as defined in the Radiation Protection Procedures Handbook.


Duties / Responsibilities

Ionising radiation must be used in accordance with the appropriate health service guidelines, legislation, and approved codes of practice, guidance notes, and other advisory documents. In particular the Ionising Radiation Regulations 2017 (IRR17) and the Ionising Radiation (Medical Exposure) Regulations 2017 (IRMER17) principally relate to occupational (including public) and patient safety, respectively. As regards to the latter, employer’s Standard Operating Procedures are in place in each departmental area which are binding on employer and staff. All new uses of radiation are subject to prior risk assessment and the use of radioactive material in the Trust is also controlled by the Environmental Permitting (England and Wales) Regulations 2018 (EPR18) and other legislation.

Lasers must be used in accordance with the Medicines and Healthcare products Regulatory Agency’s (MHRA) guidance document Lasers, intense light source systems and LEDs - guidance for safe use in medical, surgical, dental and aesthetic practices, September 2015 (the MHRA’s guidance incorporates the requirements of the Control of Artificial Optical Radiation at Work Regulations 2010), and Health and Social Care Act relating to the use of lasers. These are implemented in the Hospital by local rules. These are also binding on the employer and staff.


Policy Details

Download: PDF version
Compiled by: Andrew Moth
Ratified by: Radiation Protection Group
Date Ratified: May 2021
Date Issued: February 2022
Review Date: May 2024
Target Audience: Staff involved in the use of ionising radiation, radioisotopes and lasers
Contact name: Susan Farrell


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