Legionella prosecution at Nursing Home


Following the death of Kenneth Ibbetson, 86, who died after contracting Legionnaire’s disease at Hutton Village Care Home, Brentwood in June 2015, Bupa Care Homes (BNH) Ltd, pleaded to breaching Section 3 (1) of the Health and Safety at Work Act 1974. The company has been fined £3m and ordered to pay costs of £151,482.

While this prosecution relates to a nursing home, the lessons learned are applicable to all those involved in the built environment. This QNote focuses on the failures made and considers what preventative methods should be implemented to avoid a similar event.

What is Legionnaires disease?

Legionnaires’ disease is a collective term for a potentially fatal form of pneumonia caused by inhaling water aerosols contaminated with legionella bacteria. Water systems which produce aerosols present a higher risk, eg cooling towers, showers, spas and spray taps. People more at risk are those over 45, smokers, heavy drinkers and the immuno-suppressed.

What happened?

Kenneth Ibbetson moved into Hutton Village Care Home on March 2015, within weeks he complained of feeling unwell. He was diagnosed with a lung Infection and died at Basildon Hospital. The family were later informed that he had contracted a severe case of Legionnaires disease.

What were the causes?

The Court were told that Legionella samples were taken from taps in Mr. Ibbetson’s en-suite bathroom in which a high concentration of the bacteria was found in the water.

The Health and Safety Executive (HSE) investigation found Bupa had failed to implement the necessary control and monitoring measures required to safely manage the homes hot and cold water system, for more than a year during refurbishment works.

In addition, the HSE found that those responsible for overseeing Legionella controls and for taking crucial water temperature measurements had not been adequately trained. An HSE inspector stated:

“Mr. Ibbetson and other residents were exposed to the risk of contracting Legionnaires’ disease because adequate controls were not in place. The risk is more acute in care home settings because residents are more susceptible due to their underlying health conditions. We would expect those who have a duty of care to understand this and have the necessary controls in place to manage the risk.”

Joan Elliot, Managing Director of Bupa Care Services stated that a number of improvements have been implemented following this incident across all care homes.

Specific legislation, codes of practice and guidance

  • The Health & Safety at Work etc. Act 1974 – Sections 2, 3 & 4.
  • The Control of Substances Hazardous to Health Regulations, 2002
  • HSE Approved Code of Practice and Guidance – Legionnaires disease. The control of legionella bacteria in water systems (L8) (2013).
  • HTM04 Part 1 (Safe water in healthcare premises) and 2 (Critical care units).

Action and Next Steps

So what preventative measures should be implemented for managed properties such as: healthcare, residential blocks, commercial office buildings and shopping centres?

  1. Ensure that responsibility for the management and control of legionella related risk is clearly identified and formally documented.
  2. A risk assessment should be completed by a competent person in relation to each property’s water system. Any improvements identified should be implemented. For more complex systems external assessors may be required.
  3. Develop, document and implement a preventative control scheme for all water assets. This should identify the tasks, frequency and those responsible for implementing.
  4. The responsible people and staff involved in managing, implementing and monitoring the preventative scheme should be competent for their role. Training records should reflect this.
  5. Records for maintenance and monitoring should be systematically recorded.
  6. Monitor that the preventative scheme is being effectively implemented and records support this.

Further Information

BBC News article: https://www.bbc.co.uk/news/uk-england-essex-44483283

Approved Code of Practice and Guidance – Legionnaires disease. The control of legionella bacteria in water systems: http://www.hse.gov.uk/pubns/books/l8.htm

For information on training courses available via the Water Management Society: https://www.wmsoc.org.uk/legionella-training-courses/5/

For information on selecting a competent water assessor: https://www.legionellacontrol.org.uk/suppliers.php