Following Mr Brooks’ death, the HSE launched an investigation which found that the Trust had failed to put in place all of the necessary precautions to minimise the risk to patients in the annex to the William Budd ward from exposure to legionella.
The investigation revealed that the annex to the William Budd Ward is on a separate loop of the hospital’s water system to that which supplies the main ward. This important fact had not been recognised by the Trust from the opening of the annex in 2009 until Mr Brooks’ death in July 2015. This failure meant the required temperature checks and tests for the presence of legionella bacteria in the water had not been carried out in the annex over this period.
Tests carried out after Mr Brooks’ death revealed problems with water temperatures in the annex and legionella bacteria were found in water samples taken from outlets in all five isolation suites in the annex to the William Budd ward.
The strain of legionella bacteria which caused Mr Brooks’ death was not the same as that found in the water system. However, HSE concluded there was sufficient evidence to prosecute the Trust for exposing patients to risks from legionella bacteria in its water systems.
Royal United Hospitals Bath NHS Foundation Trust pleaded guilty to breaching Section 3 (1) of the Health and Safety at Work etc Act 1974 and was fined £300,000 with costs of £37,451.78.
Speaking after the hearing, HSE inspector Susan Chivers said: “Legionnaires’ disease is a type of pneumonia which can be fatal and people who are being treated in hospital are especially susceptible to infection. That is what makes RUH’s failings in legionella management all the more concerning.
“RUH had measures in place to prevent and control the risk to its patients from exposure to legionella from its water systems, but these were ineffective due to the Trust not having accurate knowledge of the layout of those water systems.”
“All organisations have a responsibility to manage their water systems to protect people from the risk of legionella infection. It is essential that organisations review their risk control measures whenever there is reason to suspect that they are no longer valid or when there are changes to a water system.” After the hearing, Terence Brooks’ family gave the following statement: “The family are pleased that the HSE have pursued this and that as a result changes have been made at the RUH. Our hope is that no other family will suffer as we have.”
In this episode of the Safety & Health Podcast, ‘Burnout, stress and being human’, Heather Beach is joined by Stacy Thomson to discuss burnout, perfectionism and how to deal with burnout as an individual, as management and as an organisation.
We provide an insight on how to tackle burnout and why mental health is such a taboo subject, particularly in the workplace.
