legionella outbreaks
Post on 10-Dec-2016
232 Views
Preview:
TRANSCRIPT
IOSH Essex Branch Event
Event Subject: Legionella Outbreaks
Date: 8 December 2010
Case Study One – Barrow• Barrow Borough Council• Outbreak in 2002 from cooling tower at Forum
28• Gillian Beckingham, council employee, cleared
of seven counts of manslaughter but fined £15,000
• Council fined £125,000 and ordered to pay costs of £90,000 (which would have been more if had been a private company)
IOSH Essex Branch Event
Six Key Failures• Poor lines of communication and unclear
lines of responsibility• Failure to act on advice and concerns raised• Failure to carry out risk assessments• Poor management of contractors and
contract documentation• Inadequate training and resource• Individual failings
IOSH Essex Branch Event
Failure One
Communication and responsibility
• Lack of leadership and direction within the council
• Poor communication channels between management
• Health and safety issues not appropriately controlled
IOSH Essex Branch Event
Failure One“Organisations need to define the responsibilities
and relationships within their health and safety policy, particularly where special expertise is called for. A clear policy allows managers,
supervisors and team leaders to understand what is required from them and how they will be held
accountable. Ignorance is no excuse for failing to address serious
risks such as legionella”.
IOSH Essex Branch Event
Failure TwoFailure to act on advice and concerns raised
• Individual and corporate failings• No remedial action taken following external
audit report• Systems need to be in place to support
effective monitoring and reporting to ensure leaders are being kept informed about any significant health and safety failures
IOSH Essex Branch Event
Failure ThreeFailure to carry out risk assessments
• COSHH regulations require risk assessment• Barrow Council had failed to properly assess
the risks from legionella which was their duty as an employer
• A risk assessment and scheme should have been prepared by a “fully trained and competent person”
IOSH Essex Branch Event
Failure FourPoor contractor and contract management
• The failure by the council to properly manage contractors was “a significant factor in the cause of the outbreak”
• The council could not discharge its legal duties simply by engaging contractors
• Contractors must report system failings orally and in writing
IOSH Essex Branch Event
Failure FiveInadequate training and resource
• The council had a duty to identify all appropriate people requiring training and to make sure sufficient numbers were trained to cover absences
• Staff should have received training to ensure they were competent to carry out the work they were assigned to do
IOSH Essex Branch Event
Failure FiveInadequate training and resource
• Under HSAW Act 1974, the employer must provide such training as necessary to ensure health and safety of their employees
• Regular auditing and refresher training helps ensure people’s skills are kept up to date
IOSH Essex Branch Event
Failure SixIndividual failings
• Mrs Beckingham’s acts and omissions were more significant than others.
• There were a catalogue of errors and series of oversights that led to the outbreak
• The number of fateful coincidences involved was scarcely credible
IOSH Essex Branch Event
Failure SixIndividual failings
• These failures could have been easily prevented.
“It is hoped that …. others will be alerted to the risks of legionella and in applying the lessons will help in preventing a comparable tragedy”
IOSH Essex Branch Event
Case Study Two – HP Bulmer
• HP Bulmer and Nalco (water treatment company) fined £300,000 each plus costs of £50,000
• Direct relation to deaths of two people and 28 cases of legionnaire’s disease
• There was a failure to institute and maintain an effective cleansing treatment and disinfectant regime
IOSH Essex Branch Event
Case Study Two – HP Bulmer
“Inadequate management, by neglecting such an obvious duty of care, that can
result in the health and lives of the public or employees being endangered cannot go
unpunished.”
IOSH Essex Branch Event
Case Study Two – HP Bulmer
“The fact that building users engage a specialist contractor does not mean that
they have complied with the law; they must work with the contractor and ensure they
are receiving the service required”.
IOSH Essex Branch Event
Case Study Two – HP BulmerSummary• Failure of company to ensure the specialist
contractor was carrying out works correctly and therefore safely (same lesson as at Barrow)
• Unlimited commercial impact on business and reputation
IOSH Essex Branch Event
Case Study Three – B&Q
• Outbreak of Legionnaire’s disease in the South Gloucestershire area
• B&Q fined £20,000 after it was found that spa pool on display risked the health of more than 500,000 customers
IOSH Essex Branch Event
Case Study Three – B&QSummary• It isn’t known if training had been given but
did a lack of legionella awareness contribute to this outbreak?
• Again, commercial impact on local or even national basis and damage to reputation
IOSH Essex Branch Event
Case Study Three – B&QSummary
They were not prosecuted because they caused an incident or outbreak, but because they were found to have no
controls in place to protect the public and staff from the risk of legionella.
IOSH Essex Branch Event
Case Study Four – Deba UK
• Water treatment company Deba UK fined £41k for carrying out “inadequate and misleading legionella surveys” on water systems at nursing homes in Blaenau Gwent and Powys.
IOSH Essex Branch Event
Case Study Four – Deba UK• By not having “suitable and sufficient”
assessments the company were deemed to have placed the elderly residents at risk from Legionnaires’ disease
Note: the quality and competence of specialist contractors is crucial in ensuring compliance to legislation!!
IOSH Essex Branch Event
Other CasesApril 2008• Man died after visiting Scottish hotel complex• Legionella bacteria found in shower head and hot
tub
IOSH Essex Branch Event
Other CasesOctober 2009• Liverpool Heart & Chest Hospital fined £48,000• Unsafe levels of bacteria found in water supply• Two patients, one from Warrington and one from
the Isle of Man, later died.
IOSH Essex Branch Event
Other Cases
We were astonished to discover that the trust's management team took a decision to stop testing
for the bacteria.
Kevin JonesHSE inspector
IOSH Essex Branch Event
Other CasesSeptember 2010 • Two deaths and 22 cases between Abergavenny
and Llandarcy • A separate outbreak with two deaths and eight
further cases• “A number of potential sources”• HSE and council EHO visited > 100 workplaces• Found unregistered and untreated towers
IOSH Essex Branch Event
Technical Update
• Cooling towers account for 27% of cases, 56% unknown, 5% spa baths, HWS 5% CWS 3%
• Compost cases are on the rise, linked to the demise of peat based composts which were Legionella free (acidic) – most common species is Longbeachae but others in the mix. Compost cases in Australia account for 30% of infections
IOSH Essex Branch Event
Useful WebsitesHSE (updates, improvement notices and news)www.hse.gov.uk
HSE Barrow reportwww.Hse.gov.uk/legionnaires/barrowreport.pdf
Useful news and updateswww.h2ochemicals.co.uk/
IOSH Essex Branch Event
Any questions?
Questions
top related