An important lesson in Legionella management and large company fines

Topics covered: CQC, health and safety, prosecutions

BUPA has been fined £3million following the death of a service user who contracted Legionnaires’ disease and died. This Health and Safety Executive (HSE) prosecution is significant because it looks at large company fine levels.

Ipswich Crown Court heard that the service user moved into a BUPA care home in March 2015 and died three months later after contracting Legionnaires’ disease. BUPA pleaded to breaching Section 3 (1) of the Health and Safety at Work Act 1974, was fined £3m and ordered to pay costs of £151,482.

From 1 April 2015, the Care Quality Commission (CQC) took responsibility in England for patient and service user health and safety for providers registered with them. Prior to this, the HSE had enforcement responsibility and this is the reason for its investigation and subsequent prosecution.

The HSE investigation into the death of the service user found that for more than a year, during which time major refurbishment works were carried out, BUPA failed to implement the necessary control and monitoring measures required to safely manage their hot and cold water system. It also found that those responsible for overseeing legionella controls and for taking crucial water temperature measurements had not been trained to the required standard.

What is Legionnaires disease?  

Legionnaires disease, is a serious waterborne form of pneumonia and is usually contracted by inhaling tiny, airborne droplets containing viable legionella bacteria. Although everyone is at risk of infection, the risk is higher in care home settings because many service users are more susceptible due to their age and/or underlying health conditions.

Those with a duty of care to service users need to understand the risk of Legionnaires disease and have the necessary controls in place to manage the risk.

What are the necessary control and monitoring measures for Legionnaires management?

An employer or person in control of premises, must appoint someone to take responsibility for managing the control of any identified risk from legionella bacteria.  The responsible person should have a clear understanding of their duties and should be suitably informed, instructed and trained. They should also have the competency and knowledge to implement control measures and strategies.

A legionella risk assessment should be carried out in order to identify and assess any risks in the water system and it should identity whether:

  • water is stored or re-circulated as part of the system
  • the water temperature in some or all parts of the system is between 20–45 °C
  • there are sources of nutrients such as rust, sludge, scale and organic matters
  • conditions are present to encourage bacteria to multiply
  • it is possible for water droplets to be produced and whether they could be dispersed over a wide area for example, showers
  • it is likely that any of your employees, service users or visitors are more susceptible to infection due to age, illness, or a weakened immune system and whether they could be exposed to any contaminated water droplets

A risk assessment should include:

  • management responsibilities, including the name of responsible person and a description of the water system;
  • potential sources of risk;
  • any controls in place to control risks;
  • monitoring, inspection and maintenance procedures;
  • records of the monitoring results, inspections and checks carried out;
  • arrangements to review the risk assessment regularly


Lessons to be learnt

The BUPA prosecution case acts as a reminder to providers of the importance of having appropriate control and monitoring measures in place to safely manage the risks associated with legionella. Any providers unsure about their duties should remind themselves by referring to the HSE website, or by seeking expert advice from legionella management experts or lawyers.

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