1. IOSH Essex Branch Event Event Subject: Legionella Outbreaks Date: 8 December 2010

2. 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

3. 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

4. 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

5. 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

6. Failure Two Failure 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

7. Failure Three Failure 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

8. Failure Four Poor 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

9. Failure Five Inadequate 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

10. Failure Five Inadequate 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

11. Failure Six Individual 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

12. Failure Six Individual 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

13. 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

14. 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

15. 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

16. Case Study Two – HP Bulmer Summary 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

17. 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

18. Case Study Three – B&Q Summary 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

19. Case Study Three – B&Q Summary 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

20. 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

21. 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

22. Other Cases April 2008 Man died after visiting Scottish hotel complex Legionella bacteria found in shower head and hot tub IOSH Essex Branch Event

23. Other Cases October 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

24. Other Cases We were astonished to discover that the trust's management team took a decision to stop testing for the bacteria. Kevin Jones HSE inspector IOSH Essex Branch Event

25. Other Cases September 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

26. 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

27. Useful Websites HSE (updates, improvement notices and news) www.hse.gov.uk HSE Barrow report www.Hse.gov.uk/legionnaires/barrowreport.pdf Useful news and updates www.h2ochemicals.co.uk/ IOSH Essex Branch Event

28. Any questions? Questions