Legionnaires' Death Led to Sentence for Reading Borough Council

legionnaires disease death at care homeA 95-year-old man staying at The Willows, a care facility run by Reading Borough Council, died in 2012 after contracting Legionnaires’ disease. He was staying at The Willows for a short period while recovering from a broken leg, and was set to return home. However, he fell ill while staying there, and later died in hospital after testing positive for the legionella bacteria present in his system.

Reading Borough Council was later fined £100,000, with an additional £20,000 to be paid in costs, after admitting a breach of Section 3(1) of the Health and Safety at Work Act 1974.

What went wrong at the care home?

The investigation into the death found there had been inadequate legionella training provided for those members of staff who were required to manage this aspect of the care home. Furthermore, the temperature checks on the water system were not good enough, and some were not done correctly. For example, the thermostatic mixing valves present at the home had not been tested in the proper manner.

  • Legionella training for key personnel was significantly below the standard required
  • There were inadequate temperature checks
  • Temperature checks of Thermostatic Mixer Valves (TMVs) were done incorrectly
  • Showers were not descaled and disinfected as required
  • The schedule for flushing of little used outlets was haphazard

•    How to improve the practical skills needed for routine legionella control tasks

The Health and Safety Executive pointed to systemic failings that were not isolated to a short period, but instead continued over a longer period. Before the home was called The Willows, it had been called Tanfield Care Home. Even then, legionella checks and systems had not been adequate.

What should have been done to protect residents from legionella?

To protect residents, staff and visitors from legionella all showers must be descaled every three months, as well as being disinfected. This had not been done at the care home. Additionally, outlets that were infrequently used were not always flushed through properly. The care home had made the handyman responsible for these task, but he had not been adequately trained, and was not supervised in these tasks. Furthermore, if he was away, no other member of staff was trained in completing the checks, so they were not done.

This case shows how vital it is to ensure a location such as this has a proper plan in place to manage the risks from legionella bacteria and Legionnaires’ disease. Proper training should be given, and more than one member of staff should be responsible for the checks. This means there should always be someone who can perform them if the main person in charge is not present for any reason.

The 95-year-old man was only at The Willows temporarily, but sadly the stay led to his death – and this could easily have been prevented.

Practical skills for legionella and ACOP L8 compliance training

This case demonstrates how important it is that people involved with the control of legionella and Legionnaires’ disease receive the right training. Our practical ACOP L8 compliance based legionella training course LCA 8000 does just that. It shows people how to correctly perform a number of practical, but important routine legionella and water safety monitoring and maintenance tasks on hot and cold water systems... all in accordance with COSHH, the Health & Safety Executives ACOP L8, HSG274 and the Department of Health's HTM 04-01.

•    More on our practical legionella and ACOP L8 compliance training

This course is ideal for facilities management technicians, caretakers, housekeepers, building managers, plumbers, maintenance and engineering contractors, and those with responsibility for the routine monitoring, inspection and maintenance of hot and cold water systems including those in healthcare, hospitals and care homes.

•    More on our legionella awareness training and responsible person courses

Further information, advice and support

If you require further information or advice about compliance with the HSE's ACOP L8 please call us today on 0161 877 0586 or contact us here >>

Further reading

For additional information about this case … here >>

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