Failure to Act Highlighted Legionella Concerns in the Barrow Report
The Barrow Report was compiled following an outbreak of Legionnaires’ disease at a town centre arts and leisure facility called Forum 28 in Barrow in Furness, UK in 2002. The Health and Safety Executive led a detailed investigation into what happened, resulting in a court case a few years later.
Barrow Borough Council and their design services manager Gillian Beckingham were all acquitted of manslaughter charges stemming from the deaths of seven people. However, both the Council and the manager were found guilty of breaches of the Health and Safety at Work Act 1974.
The Health and Safety Executives Barrow Report that resulted from the outbreak was released a few years later. It laid out several failures that contributed to the outbreak of Legionnaires’ disease including the lack of suitable Legionella risk assessments and a failure to take effective action.
In this, the fourth in our series of 5 articles focussing on the Barrow outbreak of 2002, we consider how a failure to act by those with responsibility for the control of Legionella contributed significantly to the outbreak of Legionnaires’ disease.
A version of this article first appeared in Legionella Control International’s newsletter. To get it in your inbox, sign up for free here.
A failure to act – could things have been done differently to prevent the Legionnaires’ outbreak?
The second failure is mentioned in the report as a failure to act. The report makes clear that various things should have been done to prevent Legionella bacteria from getting out of control within the water systems at the Forum 28 arts centre. However, it was also clear that there were times when concerns were raised, and yet nothing was done to address those concerns.
For example, Ms Gillian Beckingham, the design services manager for Barrow Borough Council, was informed by a contractor about the lack of water treatment involving the cooling towers on site. While these concerns were recognised and acknowledged, nothing was done to share this information with other people at the Council. It was also found that the information was not shared with the managers running the arts and leisure centre, known as Forum 28.
This was one instance of a failure to act on relevant information, however. The report also highlighted correspondence sent by HSE concerning Legionella and how to control its presence, which was received by a previous manager at Forum 28. This was not acted upon and no one else at the centre seemed to have been notified of the correspondence.
A lack of health and safety risk assessments
Another example of a failure to act was seen in the lack of risk assessments conducted to determine the Council’s approach to health and safety matters. The Council was audited by an external company, and this element was highlighted by them. However, even upon receiving the audit report, nothing was done to conduct and complete the required risk assessments highlighted.
These assessments of risk are necessary to help maintain good health and safety throughout a business or venue, and do not merely apply to preventing Legionella. It was another point that indicated the overall lack of communication within the Council and those involved in the case. Furthermore, it suggested that even when concerns were raised, nothing was done to address them.
We’ve noted this failure to act twice here, firstly with the contractor mentioning the failure to provide a suitable water treatment programme for the cooling towers, and then with the external auditors highlighting the need for risk assessments.
It’s vital to be informed – and to make sure everyone is pro-active about managing workplace safety
Most people recognise the importance of health and safety in the workplace. Legionella bacteria is present within many hot and cold water systems. While it can pose a significant risk if it is allowed to multiply and take control of a water system, this is entirely preventable if the proper actions are taken.
Councils up and down the country are responsible for making sure all the buildings they own are safe to use – for workers, for visitors, and for anyone else who uses them. This process begins with proper communication between all parties concerned. Everyone should play a role in making sure they are in a safe workplace or environment. Seven people lost their lives in the Barrow outbreak, with dozens more falling ill.
The Forum 28 case in Barrow shows just how important it is to be aware of health and safety matters and of the need for proper risk assessments to take place and acted upon. These assessments should identify all possible risks in the building, identifying steps that can be taken to reduce or eliminate those risks. Elimination is best, but risk reduction is a good alternative where elimination is not possible.
Missed opportunities to control Legionella can be devastating
In this case, there were chances to remedy the situation that was clearly developing. If the correspondence from HSE had been noted and acted upon, proper steps might have been taken to prevent Legionella from getting out of control. Furthermore, if the design services manager had informed others at the Council of the contractor’s concerns about the cooling towers, remedial action could have been taken.
Communication must extend through all levels of a business or company, to ensure everyone is aware of what must be done and when. Ignorance is not sufficient – we cannot assume someone else is responsible for something without being sure, especially where the control of Legionella, and wider health and safety is concerned.
The Barrow Report also noted that workers should be able to speak to management and others in roles above theirs, letting them know if they have concerns about safety. Some people may not have the experience or knowledge to take an active role in preventing Legionella, but they can speak with someone who does take on that role.
What can we learn from the Barrow in Furness Legionnaires’ disease outbreak?
There is much still to learn from the outbreak, even over 20 years later. If something positive is to come from the outbreak, it is surely learning from the failures that occurred on that occasion. It will do nothing to bring back those who sadly died, but it will hopefully inform and support others going forward.
Communication is the most important factor here. Learning how to share information for the good of all those working at the venue is essential. It should also be clear who is responsible for what, and how to action things when required. There were several instances where things could have been done to prevent what happened in Barrow. Hopefully, learning from what happened will mean no situation like this will ever occur in the future.
If you need advice about managing the risks from Legionella in your business, please get in touch for further information.
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