Internal Reference Number: FOI_8694
Date Request Received: 05/06/2025 00:00:00
Date Request Replied To: 17/06/2025 00:00:00
This response was sent via: By Email
Request Summary: formaldehyde exposure control and compliance with COSHH (2002) legislation
Request Category: Private Individuals
| Question Number 1: I am writing under the Freedom of Information Act (2000) to enquire about formaldehyde exposure control and compliance with COSHH (2002) legislation in your Trust鈥檚 histopathology department. Formaldehyde is classified as a Class 1B carcinogen under UK CLP regulations and is therefore a 鈥渃arcinogen鈥� with respect to COSHH (2002) legislation. COSHH section 7(7) states that formaldehyde exposure control is adequate only if: 鈥� 鈥渢he principles of good control practice are applied, 鈥� any WEL is not exceeded, and 鈥� exposure to asthmagens, carcinogens and mutagens are reduced to as low as is reasonably practicable (ALARP).鈥� Accordingly, 1. Can the Trust provide evidence that formaldehyde exposure in its histopathology department(s) is kept as low as reasonably practicable, noting that compliance with the WEL is necessary but not sufficient to demonstrate adequate control COSHH Section 7(5)(a) states that: 鈥溾��.where it is not reasonably practicable to prevent exposure to a carcinogen, the employer shall apply the following measures in addition to those required by paragraph (3)鈥� (a)totally enclosing the process and handling systems, unless this is not reasonably practicable;鈥� In addition, a 鈥渉igh standard of control鈥� is required for safe handling of a known carcinogen, as outlined in Paragraph 143 of the COSHH Approved Code of Practice (L5). It is noted that enclosed ventilation cabinets are prevalent in other NHS laboratory environments (e.g. microbiology, molecular biology, etc.) demonstrating that such infrastructure is feasible, effective, and proportionate when weighed against the cost and effort involved. This sets a strong precedent that total enclosure is also reasonably practicable for work requiring exposure to formaldehyde. | |
| Answer To Question 1: The histopathology department has an internal Environmental Monitoring procedure CP-H&S-008 which documents the awareness and continuous monitoring of dangerous chemicals used within the department such as formaldehyde. The strategy is based on the Health and Safety document 鈥� G409 Exposure measurement: air sampling control approach 4 special document produced by the Health and Safety Executive. Within this document sets out the internal monitoring system used, how it is used and the maximum measurement of uncertainty of the monitoring system. An additional measurement of environmental monitoring for formaldehyde is also included within this document as a verification procedure to ensure we are not breaching the 2ppm exposure limits. 1. There is a primary environmental monitoring procedure for the measurement of formaldehyde using the Drager Accuro system. 2. A secondary and confirmatory method is also employed every 3 months using the UMEX-500-100 Formaldehdye monitoring badges to measure and confirm the STEL and LEL. Areas identified as the highest risk of exposure which may breach the WEL have additional safety measures in place to protect staff, this includes the use of a 3M half mask respirator with 6075 A1+ Form filters which are for the specific use with formaldehyde. Staff are also supplied with goggles, gloves and lab coats. Copies of the COSHH records are stored within the laboratory for easy access and copies are also stored digitally. All use and handling of 10% neutral buffered formaldehyde is done so over 2 downdraft AFOS benches which are serviced yearly by AFOS. Use and handling of the 37% formaldehyde concentrate is done so within a ducted fume cabinet which is serviced annually. | |
| Question Number 2: If the Trust has decided that totally enclosing the handling of formaldehyde is not reasonably practicable in its histopathology department(s), please provide the formal assessment that was used to reach this conclusion | |
| Answer To Question 2: Not applicable - The Trust has not carried out a formal assessment as they devolve responsibility for formaldehyde control to the department using it. This takes place in liaison with our Health and Safety department. Measured levels in the department and the appropriate use of PPE and downdraft/extract equipment mitigate risks from exposure. | |
| Question Number 3: If no such formal assessment has taken place, please state this and clarify the reasons why this has not been done | |
| Answer To Question 3: Not applicable - The Trust has not carried out a formal assessment as they devolve responsibility for formaldehyde control to the department using it. This takes place in liaison with our Health and Safety department. Measured levels in the department and the appropriate use of PPE and downdraft/extract equipment mitigate risks from exposure. | |
| Question Number 4: If the Trust relies on open systems for formaldehyde handling (e.g. AFOS tables and LEV), please justify how this represents a 鈥渉igh standard of control鈥� with respect to formaldehyde exposure in the Trust鈥檚 histopathology department(s) | |
| Answer To Question 4: Please refer to Question 1 Additional monitoring procedures include monitoring of mask filter use, when filters require changing and more stock ordering to ensure an adequate supply of filters. | |
| Question Number 5: COSHH Section 7(4)(c) states that certain measures should be employed with respect to formaldehyde exposure, specifically including: 鈥淩educing, to the minimum required for the work concerned鈥� (i)the number of employees subject to exposure, (ii)the level and duration of exposure, and (iii)the quantity of substances hazardous to health present at the workplace;鈥� 5. Can the Trust provide evidence of the procedures and processes employed in its histopathology department(s) to maintain compliance with the COSHH Section 7(4)(c) | |
| Answer To Question 5: The COSHH for Histopathology is updated by the Health and Safety officer within the department according to the Trust COSHH Policy. | |
| Question Number 6: Can the Trust confirm if laboratory employees are expected to undertake duties not directly related to the dissection of human tissue (for example, administrative tasks), in environments exposed to formaldehyde | |
| Answer To Question 6: Staff are not expected to complete administrative duties, which are not directly linked to specimen dissection in an environment exposed to formaldehyde. | |
| Question Number 7: COSHH Section 10(3) states that monitoring of formaldehyde should be undertaken: 鈥�(a)at regular intervals; and (b)when any change occurs which may affect that exposure鈥� Accordingly, Can the Trust provide evidence that the frequency with which it monitors formaldehyde exposure in its histopathology department(s) is at least as frequent as when any change occurs that may affect exposure | |
| Answer To Question 7: According to the departments CP-H&S-008 鈥� Environmental monitoring procedure, the following areas are monitored weekly: 路 The following readings are taken for formaldehyde: 路 Monday morning in the dissection room 路 Friday morning post specimen disposal Ad hoc readings are taken during times of spillage and when smells/vapours appear stronger than normal. | |
| Question Number 8: COSHH Section 12 sets out information that should be provided to staff who are exposed to formaldehyde, and specifically Section 2 includes: 鈥�(a)details of the substances hazardous to health to which the employee is liable to be exposed including鈥� (i)the names of those substances and the risk which they present to health,鈥� And also: 鈥�(d) the results of any monitoring of exposure in accordance with regulation 10 and, in particular, in the case of a substance hazardous to health for which a workplace exposure limit has been approved, the employee or his representatives shall be informed forthwith, if the results of such monitoring show that the workplace exposure limit has been exceeded;鈥� Accordingly, 8. Please provide evidence that the Trust has informed its histopathology staff that formaldehyde is a known human carcinogen and provided details regarding the specific malignancies associated therein, and has also provided education regarding the non-cancer-related health effects of formaldehyde exposure | |
| Answer To Question 8: All staff receive a departmental induction when beginning work. This includes an overview of the health and safety aspects of the department, the reagents used within the department, spillage training and access to the COSHH for all reagents used within the department. | |
| Question Number 9: Please provide evidence of the procedures and processes in place to provide the results of formaldehyde exposure monitoring to staff, including but not limited to when the work exposure limit is breached | |
| Answer To Question 9: Any breaches of the work exposure limits for formaldehyde are discussed at the monthly laboratory meetings as documented in the agenda document. | |
| Question Number 10: The International Labour Organisation, of which the UK is a member and therefore bound by its obligations and commitments, now formally recognises that 鈥渁 safe and healthy working environment鈥� is a fundamental principle and right at work under its amended Declaration on Fundamental Principles and Rights at Work (2022). Accordingly, 10. Can the Trust provide evidence that its histopathology department(s) are safe and healthy working environments? | |
| Answer To Question 10: Not applicable - If this is in reference to formaldehyde levels then we can provide a log of measured levels within the department which demonstrate we meet appropriate safety criteria and provide a safe environment for our staff. If it is relation to something else, then please clarify. | |
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