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August 6, 2009

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Legionella risks prompts factory closure

A butchery processing company has closed one of its factories following an outbreak of Legionnaires’ disease.

Preston Crown Court heard that the Health Protection Agency notified the HSE, on 26 September 2008, that an employee at Kepak UK Ltd’s premises in Bamber Bridge, Preston had been diagnosed with Legionnaires’ disease — a potentially fatal form of pneumonia.

The HSE visited the site on the same day and reviewed the firm’s risk assessment and control measures for the disease. Inspectors identified a pressure-washer system, which distributed water around the factory, as the potential source of the contamination.

On 3 October a second employee at the site was diagnosed with the illness. Following the notification of the second case, an outbreak committee was formed, which comprised the HSE, South Ribble Borough Council environmental health department, Central Lancashire Primary Care Trust, the Health Protection Unit, and Lancashire Teaching Hospitals NHS Foundation Trust.

Water samples were taken throughout the building and significant levels of legionella were found to be present at two locations, which were supplied with water from the pressure-washer header tank. The tank was fed both hot and cold water, rather than just a single supply of warm water. The presence of cold water allowed the pressure-washer’s temperature to drop from 60OC to 40 OC. Any system that has a water temperature beneath 45 OC, and which releases an aerosol during operation, is at risk of exposure to legionella bacteria.

HSE Principal Inspector Dorothy Shaw said: “Kepak failed to carry out simple checks on the hot and cold water system. As a result, many of its employees working at the site were potentially exposed to the legionella bacteria, and two individuals were made seriously ill.”

Kepak UK Ltd appeared in court on 27 July and pleaded guilty to breaching s2(1) of the HSWA. It was fined £25,000 and ordered to pay £20,000 in costs.

In mitigation, the firm had no previous convictions and it permanently ceased operations at the site following the second diagnoses of the disease. It has subsequently sold its other premises in Preston, so the HSE deemed it unnecessary to issue Improvement or Prohibition Notices against the company.

Inspector Saw concluded: “Legionnaires’ disease is a potentially fatal illness and, had the correct procedures been in place, the outbreak at Kepak’s premises would not have occurred. Legionella bacteria can build up in purpose-built water systems and, if conditions are favourable, the bacteria can multiply, increasing the risk.

“A risk assessment had been carried out in May 2001, which set out that simple and periodic checks should be carried out on Kepak’s domestic water system, and that the control measures should be monitored and reviewed. But this did not happen.”

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