Ionising radiation non-compliances found at LUH

by Louise Doyle

THREE areas of non-compliance relating to ionising regulations were found at Letterkenny University Hospital following an inspection.

The announced one-day inspection in April of this year was carried out by two Health Information and Quality Authority (HIQA) inspectors.


The health watchdog published 22 reports assessing compliance with medical exposure to ionising regulations at hospitals and health settings.

Of the 12 regulations assessed in LUH, the hospital was compliant or substantially compliant in nine of them and non-compliant in the three areas of referrers, practitioners and justification of medical exposure.

In relation to referrers, inspectors reviewed referral documentation, a sample of referrals for medical radiological procedures from CT, general X-ray, theatre and DXA and spoke with staff in relation to medical radiological procedure referral.

While inspectors were satisfied LUH only accepted referrals from appropriately recognised referrers, some imaging referral reviewed for the DXA service demonstrated that individuals who did not meet the standards and requirements as set down by the relevant professional body had been accepted.

The inspectors found non compliance in the regulation of practitioners.

The report states: “While clinical responsibility for individual medical exposures was found to be taken by an individual entitled to act as a practitioner in most areas in the hospital, inspectors found that clinical responsibility for medical exposures in a subset of DXA procedures had been taken by individuals not recognised to act as a practitioner in the regulations.”

Justification of medical exposures was deemed by inspectors as not compliant.


Inspectors visited the clinical area and observed multiple posters, both general and procedure specific, which provided service users with information relating to the benefits and risks associated with the radiation dose from a range of medical exposures.

The report states that inspectors were informed that a system to record practitioner justification in advance of all medical radiological procedures had been developed but it had not been implemented at the time of inspection.

Overall, HIQA found that LUH provides a satisfactory framework for the protection of service users who may be exposed to ionising radiation.

LUH responded to the issues of non-compliance.

In terms of referrers, it stated it will no longer accept referrals from non-practitioners, or from Advanced Nurse Practitioners that have not completed the relevant referral training course.

On the issue of practitioners, the hospital confirmed its protocols were changing to ensure that clinical responsibility for medical exposures relating to DXA scans will be completed by the Radiographer practitioner, in compliance with departmental

On the justification regulation, protocols changed in June to ensure that all decisions are appropriately approved and noted in patient files.

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