A hospital trust has been ordered to pay over £350,000 for two separate incidents, one of which involved the death of a patient who contracted Legionnaires’ Disease.
Raymond Cackett, 54, died in March 2010 after developing the disease, which also contributed to the death of James Compton, 74, in June 2007.
In both cases legionella was deemed to be a significant contributor to the deaths.
During 2006 and 2010, a further five patients and one visitor at Basildon and Thurrock University Hospitals NHS Foundation Trust were infected with legionella.
The prosecution follows an earlier prosecution of the Trust in 2004 for failure to manage the risk from exposure to legionella. The Trust pleaded guilty and was fined £25,000.
On 3 September, Chelmsford Crown Court heard that a legionella investigation by the HSE found the Trust had failed to monitor the hot and cold water systems adequately or ensure key parts of the system, such as shower heads and hoses, were kept clean.
The investigation was initiated by an outbreak of legionella in June 2007 involving three patients and was extended as a result of two further cases in December 2009 and two more in 2010.
The HSE worked alongside the Care Quality Commission to support the Trust to improve its management of the controls for legionella and to monitor progress through written guidance and enforcement action.
On 4 September, Basildon and Thurrock University Hospitals NHS Foundation Trust was fined £100,000 with costs of £162,000 after admitting breaching section 3(1) of the HSWA 1974 for the period between 28 February 2004 and 31 December 2010 in relation to legionella cases.
Following the prosecution, HSE inspector Susan Matthews said: “People being treated in hospitals are especially susceptible to infection. That is what makes these failings in legionella management all the more concerning.
“The Trust received numerous warnings from regulators, and consultants brought in to give the hospital advice and support, but these were not fully heeded.
“The Trust also failed to learn lessons from a previous prosecution after a death in 2002, despite having recognised that systems in place were not appropriate to protect the health and safety of its patients and visitors.”
In mitigation the Trust had spent approximately £3million on works directly linked to the legionella problem and were trying to address the problem, although they accepted and regretted that opportunities were missed. The Trust has also installed a new management team, including a new chief executive.
Since 2011, there have been no cases of Legionnaires’ Disease, and supporting agencies and experts are working with the HSE and the Trust to prevent further outbreaks.
Chief executive Clare Panniker said: “We continue to invest significantly in upgrading and managing our water systems to minimise the risks of any patients contracting Legionnaires’ Disease in the future.”
In separate proceedings, the Trust was also sentenced after an 80-year-old patient fell nearly five metres from an inadequately restricted window in 2012, breaking her back and ankle.
The court heard that the elderly woman was found outside Basildon and Thurrock Hospital’s Horndon ward by two security guards on 23 June 2012.
The woman, who had Alzheimer’s disease, had been admitted to the Jubilee Wing of Basildon hospital for safeguarding.
An investigation by the HSE identified failings relating to ineffective window restrictors.
According to NHS guidance, the Trust should have undertaken a risk assessment and devised a window safety policy to ensure no windows, other than those on the ground floor, should open by more than 10 centimeters.
The HSE said the Trust did not have a clear policy identifying the risks associated with windows, and employees who were expected to undertake window safety checks had received no training or instruction on how to carry out their duties correctly.
Basildon and Thurrock University Hospitals NHS Foundation Trust was fined a further £75,000 with costs of £13,000 after pleading guilty to breaching section 3(1) of the HSWA 1974.
Following the prosecution, HSE inspector Corinne Godfrey said: “Incidents such as this are wholly preventable. Had a suitable window safety policy been in place, this elderly woman, who was known to have a form of dementia, would not have been able to open the window wide enough to fall out.”
In mitigation the Trust had all windows replaced were locked shut or made safe, and every window that needed to be restricted was replaced within a month. They also entered an early guilty plea and apologised to the patient involved. All window restrictors at the hospital are now regularly checked to ensure they are functioning within safe limits.
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