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31st May 2016

£100,000 fine for Legionnaires’ disease

A council has been prosecuted in connection with the death of an elderly resident at one of its care facilities. The man died because Legionella control arrangements weren’t good enough. Where did the council go wrong?

Vulnerable resident

95-year-old Lewis Payne (P) was staying at a care home operated by Reading Borough Council (R).  He was there to recuperate after breaking his leg, but unfortunately his health got worse rather than better. Because of ill health he was re-admitted to hospital where he was diagnosed with Legionnaires’ disease. He died two weeks later.

Legionella danger

Legionnaires’ disease is caused by exposure to Legionela bacteria growing in water systems. Even relatively simple hot and cold water systems can represent a risk, especially if there are areas of water stagnation, rust or scale, or water is held at warm temperatures (20°C -45°C). Those with responsibility for buildings must implement measures to monitor the temperature and condition within the water system so that intervention can be made before Legionella establishes itself.

Poor record

When the HSE was notified of P’s illness it investigated conditions at the care home. It found obvious problems with the way that R was running the premises. That included:

  • Inadequate temperature checks (including mistakes when trying to check the thermostatically controlled hot water temperatures)
  • Showers not being descalced and disinfected quarterly as required
  • Little used outlets which weren’t always flushed through on a weekly schedule
  • Insufficient training

In court R admitted breaching section 3(1) of the Health and Safety at Work etc. Act 1974 and was ordered to pay a £100,000 fine and £20,000 costs.

Root causes

R had appointed someone to carry out routine checks and provided a water log book for him to complete. However, they had not ensured that he was trained and supervised, despite the care home being occupied by the elderly – who are the most vulnerable to the bacteria.


Tip #1 When you appoint staff to carry out tasks as part of your Legionella control regime they must be trained. This may be a case of showing someone a simple task such as flushing through a little used tap for two minutes. If you’re relying on them to take charge, more detailed training might be warranted e.g. a Legionella awareness course (which Lighthouse provides).

Tip #2  If, like R, you have a thermostatic mixer valves to prevent scalding from hot taps, make sure staff know how to correctly check the hot water temperature. This is usually achieved by reaching under the wash basin to measure the pipe surface temperature at the incoming hot water feed.

Tip #3 The other underlying problem in R’s management regime was that there was no cover if their handyman was away. To avoid a similar situation, train sufficient staff so that your monitoring and controls are continued during absence.

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