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June 10, 2010

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Crown censure for prison service over legionella exposure

The Northern Ireland Prison Service (NIPS) has been censured over the death of an inmate from Legionnaires’ disease.

The prisoner, who was terminally ill, died in hospital on 8 February 2007 after being transferred there 10 days previously from the Health Care Unit of HMP Magilligan in Limavady, Co. Derry.

The Health and Safety Executive for Northern Ireland (HSENI) carried out a detailed investigation to determine the source of the exposure to legionella bacteria, which causes the disease, and discovered high levels of it in the Health Care Unit’s hot and cold water system.

Consequently, the regulator decided that NIPS was in breach of art.5 of the Health and Safety at Work (Northern Ireland) Order 1978 by failing to ensure, so far as is reasonably practicable, that non-employees were not exposed to risks to their health and safety. The HSENI found that the Approved Code of Practice for controlling legionella bacteria in water systems had not been followed.

The head of the HSENI’s major investigation team, Louis Burns, commented: “The system for managing health and safety at HMP Magilligan had not been effective in controlling this well-known risk. The standard was far below what is appropriate for a prison.”

Because the Prison Service is a Crown body, no criminal proceedings could be taken against it, so the HSENI instigated a Crown censure. At the hearing at HSENI headquarters in Belfast on 8 June, NIPS accepted the Crown censure but stressed that there were mitigating factors.

Speaking afterwards, Prison Service director-general Robin Masefield said: “The Prison Service regrets the outcome for this prisoner. He was terminally ill and was being cared for in the Health Care Unit of Magilligan Prison when he was exposed to infection. His weak immune system left him particularly vulnerable.

“It is clear from the HSENI finding that where more than one body is responsible for the management and oversight of contracts, that clear and accountable reporting procedures need to be in place. In this instance, the private company that was responsible for the maintenance and inspection of the water-treatment programme at the prison were not directly under contract to the Prison Service but were part of a wider Crown-Estate contract.

“Unfortunately, where the need for remedial work was identified, as in this case, it proved to be a less than satisfactory arrangement.”

When the legionella bacteria was discovered in 2007 the Prison Service carried out a rigorous investigation and made a series of changes to address the shortcomings identified by the HSENI.

Concluded the HSENI’s Mr Burns: “This case highlights the need for those in charge of premises to properly manage hot and cold water systems so as to minimise the risk from legionella bacteria, particularly where vulnerable people may be present. Where duty-holders or their agents sub-contract water-treatment programmes, it remains the duty-holder’s responsibility to ensure that every organisation providing a service is competent and fit for purpose, not just at the start of a contract but throughout the life of the contract.”

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