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General Policy
Estates, Facilities and Capital Services
Estates Services Manager (C&NE Fife)
Estates Compliance Manager
Director of Property & Asset Management
01 September 2006
20 November 2023
20 November 2026


NHS Fife acknowledges and agrees with the importance of regular and timely reviews of policy statements and aims to review policies within the timescale set out.

New policies will be subject to a review date of no more than 1 year from the date of the first issue. Reviewed policies will have a review date set that is relevant to the content (advised by the author) but will be no longer than 3 years.

If the policy is past its review date, then the content will remain extant until such time as the policy review is complete and the new version published.


1.1 This policy outlines the principles to be adopted and implemented in order to achieve the objectives set out in legislation and other related guidance documents, specifically the Control of Substances Hazardous to Health Regulations 2002 and any associated amendments.


2.1 This Policy is Applicable to all NHS Fife premises owned by, leased by or those where NHS Fife services are delivered.


3.1 Chief Executive

The Chief Executive of NHS Fife has overall executive responsibility for ensuring that effective arrangements are in place to manage all safety, health and risk matters within NHS Fife. This responsibility has been delegated to an appropriate senior manager, The Director of Property and Asset Management, but the Chief Executive remains accountable to the Board.

3.2 The Director of Property & Asset Management is the Executive Lead for Health and Safety and is responsible for:

• Making sure that the Board regularly reviews the effectiveness of the policy.

3.3 Director of Property & Asset Management

Through the Head of Estates is responsible for ensuring:

• The implementation and management of this policy and associated procedures across NHS Fife.
• That NHS Fife staff are aware of and have access to this policy and associated procedures.
• That NHS Fife staff understand the importance of compliance with the procedures associated with this policy.
• That NHS Fife staff involved in the decontamination of Mercury spillage and the disposal of Mercury, have been provided with adequate information and training to carry out their responsibilities.

3.4 Estates Managers & Medical Equipment Manager

• All relevant staff groups must be aware of the policy and implement the associated procedures and their designated responsibilities.
• Ensure that they and all of their staff undertake appropriate training in line with their roles and responsibilities in relation to this policy, associated procedure and their implementation.
• Identify hazards and ensure the process of risk avoidance, risk assessment and risk reduction, is implemented within their area of responsibility. They can nominate competent staff to assist in this process. Departments where mercury is used should carry out a risk assessment as required by the Control of Substances Hazardous to Health (COSHH) Regulations. The assessment should not only include the risks associated with normal use but should also include the risks associated with emergency situations such as spillage.
• Ensure that all staff receives information, instruction, training and supervision in relation to mercury control.
• Provide mercury decontamination equipment in the form of a spillage kit, and encourage the use of such equipment where provided, ensuring that there is a procedure in place for cleaning and maintenance of all equipment containing mercury.
• Follow up all accidents, incidents and near misses associated with mercury.
• Maintain records of incidents involving individual employees.
• Monitor trends of sickness absence related to mercury risks.
• Employers, through the Occupational Health Dept, must report to the Health and Safety Executive any case of poisoning by mercury or one of its compounds occurring amongst their workforces.

3.5 Members of Staff

• Taking reasonable care of themselves and others who may be affected by their actions.
• Co-operating by following rules and procedures designed for the control of Mercury.
• Reporting all incidents that may affect the health and safety of themselves or others and asking for guidance as appropriate.
• Reporting any risks they identify or any concerns they might have in respect of Mercury management.
• Taking part in training designed to meet the requirements of the policy.


4.1 NHS Fife aims to comply with the requirements of the Control of Substances Hazardous to Health Regulations and its associated amendments. See Guidance on Management of Risks Associated with Control of Mercury for further information and guidance.

4.2 The aim will be achieved by ensuring there is an effective and proactive Control of Mercury management system in place encompassing:
• Identification and allocation of resources for the planning and implementation of this policy.
• Monitoring the implementation of plans and compliance with standards.
• Reviewing of the policy as a result of monitoring and auditing.
• Identifying substances with the potential to cause harm.
• Ensuring that no work that may expose employees to any harmful substances is undertaken until inspections and risk assessments are carried out to identify risks arising from that work and mitigations have been implemented to reduce the identified risks.
• Providing all employees with suitable and sufficient information, instruction and training about substances to which they may be exposed, and the risks created by such exposure and the precautions they should take to protect themselves and others.
• Ensuring that any such exposure to harmful substances is either prevented or, where this is not reasonably practicable, then it is adequately controlled.
• Ensuring that where control measures have been introduced e.g., engineering controls, personal protective equipment (PPE), that these are effectively monitored, properly used and that staff are adequately trained in its purpose and its use.
• Ensuring that where control measures are employed that they are regularly tested, properly maintained in good working order and that personal protective equipment is also properly maintained, clean, with adequate storage facilities and promptly replaced when the need arises.


The key risks involved in implementation of this policy are:
• Lack of staff awareness of this policy, resulting in non-compliance.
• Lack of robust organisational arrangements around policy implementation.
• Failure to implement and maintain the required procedures associated with the policy.


This section details the documentation relating to this Policy. It is recommended that this document is read in conjunction with the following:

• Guidance on Management of Risks Associated with Control of Mercury
• Control of Substances Hazardous to Health Regulations 2002. Approved Code of Practice and guidance L5 (sixth edition).


7.1 Statute, Legal and Guidance
Health and Safety at Work Act 1974
The Management of Health and Safety at Work Regulations 1999
Personal Protective Equipment at Work (Amendment) Regulations 2022
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013
Special Waste Amendment (Scotland) Amendment Regulations 2004
Provision and Use of Work Equipment Regulations 1998
Control of Substances Hazardous to Health Regulations 2002
Control of Substances Hazardous to Health (Amendment) Regulations 2004
• Elemental Mercury – A Practical Problem for Environmental and Health Professionals Colin F Clark, T Crombie & P Morris
• Mercury Safety Products Ltd 1006 – Recommendations
• The Hazards of Mercury Spillages D Anderton, BPharm, MPA
• Mercury Discharges to Sewer Healthcare Engineering & Environment Unit, Glasgow 1996