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NHS Trust fined after exposing patients to legionella risk

Date:
20 April 2018

Royal United Hospitals Bath NHS Foundation Trust has been fined £300,000 after failing to control the risk to patients from exposure to legionella bacteria in its water systems.

Bristol Crown Court heard how, in July 2015, Mr Terence Brooks, a 68-year-old patient at Bath’s Royal United Hospital, died from legionnaires’ disease. Following Mr Brooks’ death, the Health and Safety Executive (HSE) launched an investigation which found that the Trust had failed to put in place all of the necessary precautions to minimise the risk to patients in the annex to the William Budd ward from exposure to legionella.

HSE’s investigation revealed that the annex to the William Budd Ward is on a separate loop of the hospital’s water system to that which supplies the main ward. This important fact had not been recognised by the Trust from the opening of the annex in 2009 until Mr Brooks’ death in July 2015. This failure meant the required temperature checks and tests for the presence of legionella bacteria in the water had not been carried out in the annex over this period.

Tests carried out after Mr Brooks’ death revealed problems with water temperatures in the annex and legionella bacteria were found in water samples taken from outlets in all five isolation suites in the annex to the William Budd ward.

The strain of legionella bacteria which caused Mr Brooks’ death was not the same as that found in the water system. However, HSE concluded there was sufficient evidence to prosecute the Trust for exposing patients to risks from legionella bacteria in its water systems.

Royal United Hospitals Bath NHS Foundation Trust pleaded guilty to breaching Section 3 (1) of the Health and Safety at Work etc Act 1974 and has been fined £300,000 and ordered to pay costs of £37,451.78.

Speaking after the hearing, HSE inspector Susan Chivers said: “Legionnaires’ disease is a type of pneumonia which can be fatal and people who are being treated in hospital are especially susceptible to infection. That is what makes RUH’s failings in legionella management all the more concerning.

“RUH had measures in place to prevent and control the risk to its patients from exposure to legionella from its water systems, but these were ineffective due to the Trust not having accurate knowledge of the layout of those water systems.”

“All organisations have a responsibility to manage their water systems to protect people from the risk of legionella infection. It is essential that organisations review their risk control measures whenever there is reason to suspect that they are no longer valid or when there are changes to a water system.” After the hearing, Terence Brooks’ family gave the following statement: “The family are pleased that the HSE have pursued this and that as a result changes have been made at the RUH. Our hope is that no other family will suffer as we have.”

Notes to Editors:

1.           The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise. www.hse.gov.uk

  1. More about the legislation referred to in this case can be found at: www.legislation.gov.uk
  2. HSE news releases are available at http://press.hse.gov.uk
  3. A memorandum of understanding between the Care Quality Commission (CQC) and HSE now gives CQC the responsibility for enforcing legionella control measures where there are risks to patients from legionella in hospital water systems.
  4. For further information on legionella control visit: http://www.hse.gov.uk/legionnaires/index.htm

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