NHS trust fined £300k over failure to control risk of legionnaires disease

A NHS trust has been fined £300,000 after failing to control the risk to patients from exposure to legionella bacteria in its water systems.

The Health & Safety Executive conducted an investigation into the Royal United Hospitals Bath NHS Foundation Trust after the death of Terence Brooks, a 68-year-old patient, in July 2015 from legionnaires’ disease.

This 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.

The annex is on a separate loop of the hospital’s water system to that which supplies the main ward, but this had not been recognised by the Trust from the opening of the annex in 2009 until Mr Brooks’ death in July 2015.

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“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,” the HSE said.

It added that 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, the 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 at Bristol Crown Court to breaching Section 3 (1) of the Health and Safety at Work etc Act 1974.

In addition to the £300,000 fine, it was ordered to pay costs of £37,451.78.

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 said in a 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.”

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