Health Board Fined after Patient Contracts Legionnaires' Disease

CROWN OFFICE AND PROCURATOR FISCAL SERVICE

NEWS RELEASE

 

27 JANUARY 2012

 

HEALTH BOARD FINED AFTER PATIENT CONTRACTS LEGIONNAIRES’ DISEASE
 
 
At Hamilton Sheriff Court today, Lanarkshire Health Board was fined £24,000 for a breach of Section 3 of the Health and Safety at Work etc Act 1974, which led to the serious illness of a hospital patient.
 
Over the course of November 2008, the 64-year old female patient at Hartwoodhill Hospital became gravely unwell. 
 
She was admitted to Wishaw General Hospital, where it was discovered that she was suffering from pneumonia and severe sepsis and was diagnosed as having Legionnaires’ Disease. She was treated with intravenous antibiotics, but required to undergo a tracheotomy on 1 December 2008. She returned to Hartwoodhill Hospital on 23 December.
 
An investigation by the Health and Safety Executive (“HSE”) identified that legionella bacteria was present in three sources in the water system at the hospital. Two of those sources, including the shower used by the patient on a daily basis, matched the strain of legionella bacteria that had caused her illness. The HSE investigation also established that a suitable and sufficient assessment of the risks from the potential presence of legionella bacteria to persons using the facilities had not been carried out, nor was there a safe scheme in place to manage and control the risks of exposure to that form of bacteria in the water system at Hartwoodhill Hospital.
 
At the time of the discovery of the legionella bacteria, the premises were in the midst of a demolition programme, which had the potential to disrupt the water system. Fewer patients were in the hospital resulting in reduced demand on the water supply and the demolition work would have increased the possibility of dirt and debris, which would provide a source of nutrients for the bacteria getting into the system.   Both of these factors would have increased the overall risk of the system and should have triggered a review of any assessment in order to decide whether any additional measures would be required to maintain control of water quality. 
 
 
Following the case, Elaine Taylor, Head of the COPFS Health and Safety Division, said:
 
“Over a significant period of time there was no suitable and sufficient assessment or management of the risks of there being legionella bacteria at Hartwoodhill. This resulted in members of the public, including patients who were relying on the hospital for their care, to be exposed to a risk from the bacteria. For one lady that exposure resulted in her contracting Legionnaires’ disease, becoming very unwell and requiring surgery. The events were entirely avoidable. 
 
“It is vital that there is proper and effective management of water systems when the potential presence of legionella bacteria is a risk.
 
“Legionnaires’ disease is a very dangerous illness and those who fail to manage their systems adequately and expose persons to risk of contracting it, whether private companies or bodies such as Health Boards, can expect to be prosecuted.”
 
 
HSE Inspector Mike Orr said:
"This investigation highlights the importance of having robust management arrangements in place to ensure that the risk from legionella is controlled. This is particularly important where potentially vulnerable groups, such as patients in hospitals, are at risk.
 
“Responsibility for implementing the arrangements should be assigned to a competent senior manager and the effectiveness of the arrangements should be subject to monitoring." 
 
HSE provides comprehensive guidance on how to manage the risk from legionella, which can be found at : http://www.hse.gov.uk/legionnaires/index.htm
 
 
Ends
 
 
Notes to Editors
 
1) Lanarkshire Health Board pled guilty to a breach of Section 3.   They were fined £24 000,(reduced from £35 000 as a result of their guilty plea)
 
          (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.”)
 
2) Exposure to the legionella bacteria can lead to the development of Legionnaires’ disease, which is a potentially fatal form of pneumonia. It can be treated effectively with antibiotics though can prove fatal in approximately 12% of reported cases. It is understood that this rate is higher amongst those who are susceptible because of age, illness, immunosuppression, smoking etc.
 
3) In Scotland the Crown Office and Procurator Fiscal Service has sole responsibility for the raising of criminal proceedings for breaches of health and safety legislation. Its Health and Safety Division has ten specialist prosecutors in a team of 16 based at three units in Aberdeen, Edinburgh and Glasgow. The Division was officially launched by the Solicitor General in July 2009.
 
4) The Division deals with all health and safety prosecutions and any Fatal Accident Inquiries requiring specialist health and safety input. Some work-related Fatal Accident Inquiries are dealt with by local Procurator Fiscal Offices, with support from the Division as required.
 
5) The Health and Safety Executive is Britain's national regulator for workplace health and safety. It aims to prevent 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. www.hse.gov.uk
 
Communications
0844 561 3984