How a Lack of Legionella Training Contributed to Devastating Legionnaires’ Outbreak
In this article we examine the impact of inadequate Legionella training and a lack of available resources on an organisations ability to control Legionella risks effectively, meet its water safety compliance obligations, and ultimately keep people safe. The article highlights how a detailed understanding of such failings can be used to modify behaviours to prevent future outbreaks of Legionnaires’ disease.
In this, the last in our series of 5 articles reviewing the major failings identified by the Health and Safety Executive following the outbreak of Legionnaires’ disease at Barrow-in-Furness, UK in August 2002 we look at the last of the key failings … inadequate Legionella training and a lack of resources.
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Inadequate Legionella training and a lack of resources
We’ve been running a series of articles looking at various aspects of the Legionnaires’ disease outbreak in Barrow in Furness, Cumbria that occurred in 2002. This outbreak, the largest in the UK took the lives of seven people, while many more fell ill after being exposed to Legionella contaminated aerosols emitted from an air conditioning unit used at the towns Forum-28 arts centre.
After the trials concluded, public meetings took place that resulted in the publication of the Barrow Report by the Health and Safety Executive (HSE). That report listed several key failures that contributed to what happened at the council-run arts and leisure centre where the outbreak occurred.
In this article, we’ll look at the fifth failure to be noted in that report. It pointed to inadequate Legionella training and a lack of resources, both of which contributed to what happened.
The importance of health and safety in the workplace
We should all be familiar with the Health and Safety at Work etc. Act 1974, as it lays the ground rules for protecting us all in the workplace, from business owners to managers and day-to-day employees. It also covers the safety of anyone who comes into contact with a building or business. In the case of the Barrow outbreak of Legionnaires’ disease, the air conditioning unit used at the Forum-28 centre that had been insufficiently maintained, vented out into an alleyway that was accessible to the public.
The HSE’s Barrow Report noted that Barrow Borough Council had not adequately resourced its health and safety processes or management. The resources that were available were found to be reactive. That is, they reacted to any breakdowns, concerns or issues that were highlighted by others in the building, rather than taking steps to act to eliminate those risks to start with. There was a shortage of Legionella and other risk assessments undertaken too, something that was also highlighted in another of the failings mentioned in the report. You can read more about this topic in another of the articles in this series.
A lack of Legionella training led to multiple problems
In this instance, the Council should have recognised individuals who required water safety and Legionella training to do their jobs properly. Furthermore, there should have been enough people who were trained and experienced in health and safety and the management of Legionella to cover anyone who was off work. This did not happen.
Employers must always provide suitable training for their employees, to ensure they know how to stay safe at work and to minimise the risk of incidents or accidents. The report noted that certain groups of people are more likely to require training, such as new recruits and those who are advancing to another position with different responsibilities.
How might a lack of training affect those responsible for managing Legionella risks?
There must be a responsible person in charge of controlling the risks from Legionella and other waterborne bacteria in all workplaces. This individual must be responsible, have access to sufficient resources and have the required knowledge and experience to perform their role correctly. If this is not the case, they can enlist the services of an external individual or business that does possess the required skills. However, the appointed responsible person does still carry the responsibility of the role. They must make sure nothing goes wrong.
There are various accredited training courses that individuals can take to give them the required skills and abilities to perform this role. According to the Barrow Report, there appears to have been a lack of training across the board in terms of health and safety, and with a specific focus on Legionella safety training.
The report also noted that when a situation occurs where one or more posts are unfilled, this should not lead to a lack of health and safety duties being undertaken. It is the responsibility of those in charge to make sure other steps are taken to meet all the required standards. That could mean enlisting outside help from experts in health and safety or Legionella safety, for example.
What can we learn from this lack of training and resources?
Clearly, the focus here is on training and resources. Someone working for a business who is given the role of managing health and safety should be properly trained to fulfil that role. Similarly, they should receive refresher training at suitable intervals. There should also be a clear plan to cover that individual should they be ill or on holiday. It would appear this was not done at Barrow Borough Council prior to the outbreak of Legionnaires’ disease in 2002.
The report also highlighted the importance of preventative action, rather than waiting for something to go wrong and reacting to that instead. By the time something does go wrong, it could be too late to do anything about it. We can see how a lack of training ties in with a lack of safety risk assessments too. These assessments are intended to highlight where the risks are – in this case, the risk factors that could lead to Legionella bacteria being given an opportunity to multiply throughout a cooling tower water system.
A perfect storm created by a lack of Legionella training and resources to tackle the problem effectively
With a lack of resources, the availability of trained personnel, and a lack of Legionella training, it was a perfect storm that gave the bacteria the opportunity to take control and spread. Legionella can be inhaled by humans via contaminated aerosols, and the inadequately maintained air conditioner allowed the bacteria to spread, exposing people to unnecessary risk.
It has been over 20 years since the outbreak occurred. The Barrow Report that resulted from the outbreak runs to 62 pages and serves as a sobering reminder that things can easily go wrong if proper attention is not paid to health and safety.
The report stated that many of the failures could – and should – have been prevented, had the proper steps been taken to pay attention to health and safety matters. Each error compounded upon the others, leading to one of the worst outbreaks of Legionnaires’ disease in the country thus far.
If anything can result from the outbreak, it must surely be the chance to learn from it and take steps to ensure nothing like it happens again. Legionella can be controlled if the proper steps are taken – and that’s something every business and company should do every day, without fail.
Have we learned from the past?
You might be thinking, that’s all well and good, and everybody has learned from the mistakes of the past. However, you might be surprised to learn that that’s not quite the case!
In October 2024, a UK company was fined £900,000 + costs after exposing vulnerable residents at a care facility to Legionnaires’ disease.
The HSE inspector involved in the case cited not only a failure to control contamination risks but also a lack of sufficient instruction and training for staff. You can read more here
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.
To speak with one of our Legionella safety specialists call us today on 0330 223 36 86 or contact us here …
