legionella outbreaks

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)


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


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


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”.


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


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”


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


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


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


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


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”


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



“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.”



“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”.


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


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


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


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.


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.


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!!


Other CasesApril 2008• Man died after visiting Scottish hotel complex• Legionella bacteria found in shower head and hot

tub


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.


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


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


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


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/


http://www.hse.gov.uk/legionnaires/barrowreport.pdf

http://www.h2ochemicals.co.uk/

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