Case Studies

All the following case studies/press releases can be found on the HSE website.

Case Study 1:

Manchester care home fined over Legionnaires’ risk

Date: 1 April 2010

A care home company has been fined £5,000 after putting elderly residents in Manchester at risk of catching Legionnaires’ disease.
SJ Care Homes Ltd was prosecuted by the Health and Safety Executive (HSE) after the company failed to comply with an enforcement notice issued at one of its nursing homes.
HSE Inspector Sandra Tomlinson issued the notice after a routine visit to Beech House Nursing Home on Yew Tree Lane in Wythenshawe on 24 February 2009. The visit revealed the care home did not have the required precautions in place to control legionella bacteria.

The enforcement notice gave the company six weeks to write a plan for managing the level of legionella bacteria in the care home’s water system. But when the inspector revisited on 6 April 2009, no action had been taken.
After the hearing at Trafford Magistrates’ Court, Ms Tomlinson said:
“It is vital that care homes have plans in place to make sure the level of legionella bacteria in their hot water systems does not become unsafe.
“Legionnaires’ disease is a potentially fatal form of pneumonia, which mainly affects older people and those with poor health.
“Sadly, SJ Care Homes didn’t take this risk seriously and failed to act even when we issued a formal written warning. We therefore had no other choice but to prosecute.”
SJ Care Homes, of Harrow in Middlesex, pleaded guilty to breaching Section 33(1)(g) of the Health and Safety at Work etc Act 1974 by failing to comply with an enforcement notice. The company was ordered to pay £3,607 towards the cost of the prosecution in addition to the fine at Trafford Magistrates’ Court on 7 April 2010.
Legionnaires’ disease is caused by bacteria found naturally in rivers, lakes and reservoirs, but which can multiply and become dangerous in some purpose-built water systems.

Case Study 2:

Two firms guilty over Legionella risk

Date: 28 June 2011
Fines and costs totalling nearly £250,000 have been imposed on two firms after workers and members of the public were put at risk of exposure to the potentially fatal waterborne Legionella bacteria.
The Health and Safety Executive (HSE) prosecuted multinational automotive parts manufacturer Eaton Ltd and water treatment services provider, Aegis Ltd of Felspar Road, Amington Industrial Estates, Tamworth, Staffordshire after an investigation in 2006.
Wolverhampton Crown Court heard HSE inspectors found Eaton Ltd had failed to properly manage the water cooling systems used in manufacturing processes at its plant in Thorns Road, Brierley Hill.  Aegis Ltd, which had been contracted to provide water treatment services (now trading from its Tamworth address as Aegis Water Treatment Ltd), was also found to have failed significantly in its duties.
There was no comprehensive and up-to-date risk assessment in place and neither company had taken reasonable steps to control the potential spread of Legionella by assessing the risk or properly cleaning and maintaining the water cooling system.  Employees had not been properly supervised. The management failings by both companies were present over a prolonged period of time.
Eaton Ltd, whose head office is based in Fareham, Hampshire, pleaded guilty and was fined £80,000 for breaching Section 2(1) of the Health and Safety at Work etc Act 1974 and Section 3(1) of the Act and ordered to pay £45,000 costs.  Aegis Ltd was found guilty at a trial in May and today was fined £40,000 for breaching Section 3(1) of the Health and Safety at Work etc Act 1974 and ordered to pay £80,000 costs.
After the hearing HSE Principal Inspector Paul Billinger said:
“It is vital that companies who use water cooling treatment as part of their manufacturing processes have plans in place to make sure the level of Legionella bacteria in their systems does not become unsafe.
“Legionnaires’ disease is a potentially fatal form of pneumonia, which can affect anyone coming into contact with it.
“Neither Eaton Ltd nor Aegis Ltd, which was specifically contracted to manage the water system, took the Legionella risk seriously. They failed to deal with their own risk assessment and service agreement in respect of cleaning the system.
“These were persistent and systemic failures, which put people’s health at risk.”Legionnaires’ disease is caused by bacteria found naturally in rivers, lakes and reservoirs, but which can multiply and become dangerous in some purpose-built water systems.

Case Study 3:

Health warning after Lancashire workers catch legionnaires’ disease

Date: 27 July 2009
The Health and Safety Executive (HSE) has warned companies in Lancashire to ensure they carry out regular, simple checks to protect employees from Legionnaires’ disease.
The warning follows the prosecution of butchery processing company Kepak UK Ltd after two employees caught the disease at Kepak’s Carr Place premises on the Walton Summit Industrial Estate, Bamber Bridge, Preston.
The company, which has its headquarters on Flanshaw Lane in Wakefield, was fined £25,000 and ordered to pay £20,000 in costs at Preston Crown Court on Monday 27 July. Kepak pleaded guilty to breaching Section 2(1) of the Health and Safety at Work etc Act 1974 by failing to protect its employees from the risk of contracting Legionnaires’ disease.
The court heard that the first case of Legionnaires’ disease was diagnosed on 26 September 2006 in Boguslaw Plociennik, who was employed as a boner, and a second on 3 October 2006 in Zbigniew Rauk, who was employed as a packer.
Following notification of the two cases, an outbreak committee was formed made up of HSE, South Ribble Borough Council’s Environmental Health Department, Central Lancashire Primary Care Trust, the Health Protection Unit and Lancashire Teaching Hospitals.
Water samples were taken throughout the building and significant levels of legionella were found to be present at three locations: a pressure washer hose point, an apron wash shower point, and a pressure washer header tank. The tank was fed by hot and cold water and supplied water to three pressure washer hose points in and around the process area.
Employees used the pressure washer system to clean away meat and fat debris in the various processing areas as and when required.  While the investigation was taking place, Kepak closed the Carr Place site and the domestic water system was drained, pumped through, chlorinated and disinfected. Kepak has subsequently not reopened the site, which was one of two the company operated in the Preston area.
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.
“Any system containing water at temperatures between 20 and 45 degrees Celsius, and which may release an aerosol during operation or maintenance, presents a foreseeable risk of exposure to legionella bacteria.
“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.”