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Hospital trust sentenced over fatal Legionnaires' disease and patient window fall

4 September 2013

Basildon and Thurrock University Hospitals NHS Foundation Trust has today (4 September) been ordered to pay a total of £350,000 in fines and costs for serious safety failings relating to two separate matters.

The first concerns at least seven patients being infected with legionella, the bacteria that causes Legionnaires’ Disease, from the hospital’s water system.

Fifty-four year-old Raymond Cackett died in March 2010 as a direct result of developing Legionnaires’ Disease. It also contributed to the death of 74-year-old patient James Compton in June 2007.

A further five patients were infected at the hospital between 2006 and 2010, as was a hospital visitor (See notes to editors).

The second incident involved a vulnerable 80 year-old patient falling almost five metres from an inadequately restricted window in June 2012. She suffered a broken back and ankle.

Yesterday (Tuesday 3 September), Chelmsford Crown Court heard how an investigation by the Health and Safety Executive (HSE) identified a catalogue of failures relating to both matters. In particular, the Trust failed to monitor the hot and cold water systems adequately or ensure that key parts of the system, such as the shower heads and hoses, were kept clean.

The legionella investigation was carried out between 2007 and 2010. It was initiated by an outbreak in June 2007 involving three patients and extended as a result of two further cases in December 2009 and two in 2010.

During the investigation, HSE worked alongside the Care Quality Commission to support the Trust to improve its management of the controls for legionella and to monitor progress through written guidance and enforcement action.

Basildon and Thurrock University Hospitals NHS Foundation Trust was today (4 September) fined £100,000 with costs of £162,000 after admitting breaching Section 3(1) of the Health and Safety at Work etc Act 1974 for the period between 28 February 2004 and 31 December 2010 in relation to the legionella cases.

Commenting on this part of the prosecution, HSE inspector Susan Matthews said:

"People being treated in hospitals are especially susceptible to infection. That is what makes these failings in legionella management all the more concerning.

"Not only did two families suffer the loss of their loved ones, six people suffered serious illness due to developing this potentially fatal form of pneumonia.

"Healthcare providers, like all organisations, have a legal duty to control the risks by properly maintaining hot and cold water systems.

"The Trust received numerous warnings from regulators, and consultants brought in to give the hospital advice and support, but these were not fully heeded.

"The Trust also failed to learn lessons from a previous prosecution after a death in 2002, despite having recognised that systems in place were not appropriate to protect the health and safety of its patients and visitors.

"This was a technically complex investigation and HSE will always consider prosecution where there are significant threats to the health of workers and the public."

Andrea Gordon, CQC’s regional director of operations, added:

"What happened at Basildon and Thurrock University Hospitals NHS Foundation Trust is not acceptable and CQC has worked very closely with the HSE and other regulators, including Monitor, in relation to the Trust’s performance regarding legionella.

"This work is ongoing and CQC carried out a review in April this year which looked specifically at the Trust’s processes to control legionella. The review found that the Trust had robust systems in place to manage legionella at that time.

"We will continue to monitor the Trust, including further unannounced inspections, and will not hesitate to take action where we find standards have fallen short of what people should be able to expect."

The Trust was also sentenced for separate proceedings relating to the window fall. The Court was told that an elderly woman was found outside Basildon and Thurrock Hospital’s Horndon ward by two security guards on the evening on 23 June 2012. The patient should have been in her room in the Marjorie Warren ward in the Jubilee wing.

The woman, whose family has requested she is not named, had Alzheimer’s disease and had been admitted to Basildon hospital for safeguarding.

The incident was investigated by HSE, which identified failings relating to ineffective window restrictors.

According to NHS guidance, which has been in place since 1989, the Trust should have undertaken a risk assessment and devised a window safety policy to ensure no window other than those on the ground floor should open by more than 10 centimetres.

HSE said the Trust did not have a clear policy identifying the risks associated with windows and employees who were expected to undertake window safety checks had received no training or instruction on how to carry out their duties correctly.

As a result, the restrictor on the window in the elderly patient’s room was inadequate. The window could be opened by more than 10 centimetres and she was able to climb out. She is now barely able to walk, despite having been physically fit prior to the incident.

Basildon and Thurrock University Hospitals NHS Foundation Trust pleaded guilty to breaching Regulation 3(1) of the Health and Safety at Work etc Act 1974 for this incident. It was fined a further £75,000 with additional costs of £13,000

Afterwards HSE inspector Corinne Godfrey said:

"Incidents such as this are wholly preventable. Had a suitable window safety policy been in place, this elderly woman, who was known to have a form of dementia, would not have been able to open the window wide enough to fall out.

"Every year vulnerable people are killed or severely injured in falls from windows in health and social care settings. Health and social care providers have a duty to ensure that they have a robust safety management system in place for windows, and that those tasked to undertake safety checks on key items such as window restrictors have had adequate training to do so."

Notes to editors

  1. The Health and Safety Executive is Britain’s national regulator for workplace health and safety. It aims to reduce work-related death, injury and ill health. It does so through research, information and advice; promoting training; new or revised regulations and codes of practice; and working with local authority partners by inspection, investigation and enforcement.
  2. Details of the other legionella sufferers – age is at the time of illness:
    • Egbert Van Nuil: 69, was infected with legionella in December 2006 after visiting his wife who was being treated at Basildon hospital
    • Lyn Kilshaw: 56, was infected with legionella ,after being a patient at Basildon hospital in May 2007
    • Roy Leech: 78, was infected with legionella after being a patient at Basildon hospital in May 2007
    • Joyce Limbert: 66 was infected with legionella, after being a patient at Basildon hospital in December 2009
    • Francis Nutt: 74, was infected with legionella, after being a patient at Basildon hospital in December 2009.
    • Verona Hughes: 71, was infected with legionella, after being a patient at Basildon hospital in November 2010
  3. Today’s prosecution follows an earlier prosecution of the Trust in 2004 for failure to manage the risk from exposure to legionella. The Trust pleaded guilty and was fined £25,000.
  4. Section 3(1) of the Health and Safety at Work etc Act 1974, states: "It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety."
  5. For further information on Legionella and advice on how to control risks from exposure to the bacteria, visit
  6. HSE guidance on preventing falls from windows is available at

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