Inquest found that legionella pneumonia may have hastened the death of an elderly cancer patient
Brighton and Sussex University Hospitals NHS Foundation Trust in the UK has been fined £50,000 for failing to control legionella, after a joint investigation by the Health and Safety Executive (HSE) and Sussex Police
The case follows the death of a cancer patient in November 2011, eight days after her urine tested positive for the legionella bacteria antigen. An inquest found that the patient died of natural causes and that by the time of her death, the legionella pneumonia appeared to have been successfully treated. However, the inquest found that the infection may have hastened her death.
The court heard that although the Trust was monitoring legionella and water temperatures across its various sites at the time of the death, between October 2010 and November 2011 a total of 114 positive legionella tests and a further 651 records of water temperatures outside the required parameters were not adequately acted upon.
Chloride dioxide units were fitted at five sites to control the bacteria, but HSE inspectors found they routinely failed to emit the required dosage to work effectively. Inspectors also found that water in the Jubilee building at the Royal Sussex hospital often failed to reach the 60°C temperature needed to kill off legionella, which was another control system the Trust relied upon.
The court was told that one of the major contributors to the serious control failures was the fact that staff did not have sufficient instruction, training and supervision to be able to make informed decisions and take appropriate action.
The intervention of HSE and Sussex Police resulted in a new management system to effectively control legionella.
'The legionella control failures we identified at the Royal Sussex are made all the more stark by the fact that those most at risk of contracting legionella were amongst the most vulnerable in our society – including cancer patients,' said HSE Inspector Michelle Canning. 'All organisations have a legal duty to control the risks arising from hot and cold water systems, but healthcare providers like hospital trusts must be especially vigilant and robust in terms of the systems they have in place.'