Does Poor Management Increase the Risks from Legionnaires’ Disease?
This article examines the impact of poor water safety management practices and how they increase the chances of an outbreak of Legionnaires’ disease. It looks at the relationships between those responsible for the control of Legionella bacteria in the workplace, i.e. business owners, the Duty Holder and Responsible Person; and those key contractors appointed to carry out engineering works required to maintain safe water systems in accordance with health and safety law.
The article highlights how a clear understanding of such management failings and misunderstandings between key stakeholders can be used to modify behaviours to prevent future outbreaks of Legionnaires’ disease.
In this, the third in our series of 5 articles focussing on the Barrow outbreak of Legionnaires’ in 2002, we consider why poor management processes and procedures were identified as key failings in the report by the Health and Safety Executive.
A version of this article examining the impact of poor management on the likelihood of outbreaks of Legionnaires’ disease first appeared in Legionella Control International’s newsletter. To get it in your inbox, sign up for free here.
A catalogue of failures led to the UK’s largest outbreak of Legionnaires’ disease
If you’ve been following our series of articles on the Barrow in Furness Legionnaires’ disease outbreak of 2002, you’ll know by now that several failures were highlighted in the resulting Barrow Report by the Health and Safety Executive. This was published several years after the outbreak and the trial concluded. Seven people died due to what happened, while another 180 individuals fell ill.
The outbreak of Legionnaires’ disease occurred at an arts and leisure centre in Barrow in Furness, located in North West England. The report highlighted several failures that each contributed to what happened including poor communication, a failure to carry-out Legionella risk assessments, and poor management practices. If action had been taken to prevent these failures from occurring, the outbreak would likely never have occurred. Today, the report stands as an example of what can go wrong – and of how lessons can still be learned from the incident. The report provides insight into each failure, along with giving recommendations that should help to eliminate those failures.
Poor management of Legionella risks was highlighted as a key failure in the outbreak
Barrow Borough Council took on contractors to perform certain water treatment, maintenance and safety tasks for them. However, those council employees responsible for taking on these contractors did not have a formal contract in place with them. No such contract was ever exchanged or confirmed, so there was no clear idea or agreement surrounding the work to be done. While work was specified, there was no record of this. Things were further compounded by a lack of confirmation and checks following completion of the work.
When a client enlists the help of a contractor to get a job done, both parties still retain responsibilities under the Health and Safety at Work Act 1974. This also applies if any sub-contractors are hired to help complete the required work.
Where do client – contractor responsibilities rest where water safety is concerned?
Legionella bacteria is just one of several waterborne bacteria that can proliferate in a man-made water system and potentially cause illness among those using that system or who are exposed to spray or aerosols created by it.
In this case, the Council was responsible for making sure all measures were taken to manage water safety effectively, and to appoint someone who was competent to oversee the management of the system to ensure continued safety was maintained. Under UK law it is not enough to hire someone to take on that role and never check what they’re doing is correct. The person in charge of the business or building, in this case those at Barrow Borough Council, had a clear responsibility to make sure they hired a water treatment contractor with the skills, knowledge and experience to do the job. They also had to make sure that contractor was doing what was required of them.
The lack of a formal contract and paperwork in place in this instance meant that both parties could mistakenly assume the other party was handling things. All actions should have been made clear from the outset, confirmed via a contract, and double checked to ensure they were completed satisfactorily. These checks and balances would help to highlight any errors or anything else that might have been missed.
Confusing contract terms can increase Legionella risks
The section of the Barrow Report that dealt with unclear and confusing contract terms went on to say that operators of cooling towers and similar evaporative systems were often unsure of the terms of the contracts they had with the engineering companies providing water treatment maintenance services. This lack of clarity is clearly a significant sticking point. The water treatment company believes it is adhering to what is required. The operator believes the water treatment company is handling everything… and yet in some cases, neither party is quite sure whether that is the case or not.
As I have read through the Barrow Report for the purpose of writing these posts, I’ve noticed a lack of clarity surrounding many things that went wrong and ultimately led to the Legionnaires’ disease outbreak that killed seven people and injured many others. Here, again, clear identification of all the tasks a client wants a contractor to complete should be written down, clarified, and confirmed with both parties. In these situations, the adage comes into play – if in doubt, ask. Then again, clarity should always be sought from start to finish.
Even when the water treatment contractor begins work, the client should check to make sure the work they have agreed to carry out is being done to the correct standard and at the right time. In the case of water systems of any kind, the report recommended that any problems with the system should be raised with the client, so relevant steps can be taken. This should always happen in writing, although verbally sharing the information is good too. Verbal messaging should not be the only way of communicating any issues, however. Written records are vital.
Taking on competent water treatment contractors to help keep Legionella in check is a must
Most people involved in running a business will not have the level of knowledge or experience required to understand and identify all the risks posed by Legionella bacteria in a water system. In essence, then, it is sensible to take on competent contractors to handle such tasks for you and your business.
However, we can see from the Barrow Report that problems can still occur if there isn’t enough clarity in this situation. If a contractor does not do their job properly, they will certainly hold some responsibility. However, so will the business responsible for hiring them – there is no passing the buck here.
In short, everyone should know their responsibilities in the situation, who is doing what, and when. Asking questions is something that should come naturally to be clear on what is happening. It is ultimately the responsibility of the business or company to make sure they are protecting workers, visitors, and clients from the risk of Legionella in the water systems under their control – and indeed, other waterborne bacterial risks as well.
We can all learn a lot from what happened in Barrow in Furness. Throughout the trials and the public meetings that followed, we saw many instances where actions could – and should – have been taken. Those actions would have prevented the outbreak of Legionnaires’ disease from occurring. It would have prevented loss of life and the illness of so many others. I recommend reading the HSE’s Barrow report to identify all the factors that played a role, so we can all learn from them and hopefully avoid any chance of a repeat.
World leading Legionella control specialists
Legionella Control International help business owners and those responsible for Legionella and water safety in the workplace. Our water management solutions support duty holders, the responsible person and others with responsibility for the control of waterborne pathogens including Legionella bacteria; helping them to protect staff, customers and others and so meet their legal and wider stakeholder responsibilities in this specialist area.
We deliver a full range of specialist services including legionella risk assessments, water sampling and testing, independent compliance auditing, City & Guilds training, Authorising Engineer (Water) services, expert witness support and other environmental risk management services that help keep people safe.
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