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BUPA fined £3,000,000 plus costs of £151,482 by Ipswich Crown Court for Legionella death & related failures including lack of training - June 2018


BUPA Care Homes (BNH) Ltd of Bridge House, Outwood Lane, Leeds, pleaded to breaching Section 3 (1) of the Health and Safety at Work Act 1974.  The investigation found that for more than a year, during which time major refurbishment works were carried out, BUPA Care Homes (BNH) Ltd failed to implement the necessary control and monitoring measures required to safely manage their hot and cold water system. 


It also found those responsible for overseeing legionella controls and for taking crucial water temperature measurements had not been trained to the required standard.  Summing up her findings, after hearing evidence throughout the sentencing at Ipswich Crown Court, Judge Emma Peters described that there were failings across the board from the care home operator and contractors.


In particular, she cited the lack of training and understanding regarding the control of legionella among the line manager and staff.  She also noted that problems controlling the bacteria had been brought up as early as 2012 and recommended steps had not been taken to correct these mistakes.


During a lengthy description of the evidence, Judge Peters also addressed a number of other issues Bupa had failed to deal with.  The care home’s maintenance man had been sacked in 2014 after it was found he had been falsely recording the temperatures of the water at the care home.  A replacement maintenance man was not brought in until 2015 but he also wrongly recorded numbers after failing the task.


Speaking after the hearing, HSE principal inspector Vicky Fletcher said: "I think Judge Peters’ comments and the level of fine she has imposed sends out a clear message that offences like this are taken seriously by the courts, it is heart-breaking to think Kenneth contracted Legionnaires’ a matter of weeks after moving into the Hutton Village Care Home.  His family have been left devastated by his sudden death.


“Mr Ibbetson and other residents were exposed to the risk of contracting Legionnaires’ disease because adequate controls were not in place.  The risk is more acute in care home settings because residents are more susceptible due to their underlying health conditions.  We would expect those who have a duty of care to understand this and have the necessary controls in place to manage the risk.”


“It is really important that other companies take note and take necessary reaction to control risk from legionella.  This was a serious case because the failings were there for a long period of time and there were lots of opportunities that Bupa Care Homes could have taken to remedy the issues with legionella and they didn’t do so."

Faltec Europe fined £800,000 plus costs of more than £75,000 by Newcastle Crown Court for Legionnaires outbreak - May 2018


Faltec Europe Limited of Didcot Way, Boldon in Tyne and Wear pleaded guilty to breaches of Section 2 (1) and 3 (1) of the Health and Safety at Work Act 1974.


Newcastle Crown Court heard that between October 2014 and June 2015, two employees, two agency workers and a local resident fell seriously ill with Legionnaires Disease. HSE found the illness was caused by Faltec’s failure to effectively manage its water cooling systems within the factory, causing the legionella bacteria within the water supply to grow to potentially lethal levels.


The case was originally heard at the Sunderland Magistrates Court but was referred to the Crown Court.


Speaking after the hearing, HSE inspectors Fiona McGarry and Michael Kingston said: “The outbreak of Legionnaires’ disease at the Faltec factory had a major impact on the six people affected, with some suffering long-term ill-health as a result.  In addition, the incidents raised concern amongst other employees and the local community.


“Supported by colleagues from Public Health England and South Tyneside Council HSE investigated and identified breaches in both cases.  In pleading guilty to three charges under the Health and Safety at Work Act 1974 the company have acknowledged these breaches.


Faltec Europe has been served 14 enforcement notices by the HSE since 2013, six of which relate to legionella bacteria and fire or explosion risks.  The company was handed an improvement notice in September 2013 over its failure to control the risks from legionella exposure after the HSE found drift eliminators on two of the cooling towers were damaged and ineffective at controlling aerosol drift.  It was handed another improvement notice in May 2015 after stagnant pockets of water were found in the factory’s cooling and recirculation system. Stagnation can encourage the growth of biofilm, which could contribute to Legionnaire’s disease.

The Victoria at Holkham Ltd was fined £50,000 plus costs at Huntingdon magistrates’ court after pleading guilty under the Health and Safety at Work Act 1974 for exposing its guests to a risk of scalding in its hotel - May 2018.


The water temperature in Mr Saunders’ bath had not been regulated to avoid such an injury despite the company having been informed by professionals that temperature-regulating valves needed to be fitted to the taps and that ‘Caution: very hot water’ signs should be displayed.


North Norfolk District Council said the risk occurred because the Victoria had addressed the risk of legionella infection in a manner so as to create a scalding risk.  The company had also declined to follow professional advice to display hot-water warning signs as it felt this would detract from the aesthetics of the decor.

Forest Gate surgery faces closure following ‘inadequate’ rating from the CQC inc Legionella failings – May 2018


A GP surgery in Forest Gate faces closure unless it improves the care offered to its patients within six months.  The surgery, run by Dr Gauri Shanker, was rated ‘inadequate’ overall, as well as for being safe, effective, caring and well-led.


“It is always disappointing when a practice slips from ‘requires improvement’ to ‘inadequate’, as has happened at Upton Lane Medical Practice,” said Michele Golden from health watchdog the Care Quality Commission (CQC), citing the surgery’s previous rating last year.  She added: “Special measures will give people who use the service the reassurance that the care they get should improve.  Services placed in special measures will be inspected again within six months.  If there is not enough improvement we may use our enforcement powers".  Risks to patients were not assessed and well managed, including infection control, legionella, fire safety and equipment, CQC inspectors noted.


The most recent legionella risk assessment was dated May 2016, they said, adding: “staff told us every action to ensure patient safety had been taken but this was not the case and actions in response to a previous legionella risk assessment dated 2011 were insufficient.”

JTF Wholesale has been fined £1,000,000 plus costs by Stafford Crown Court following the deaths of two men from Legionnaires disease - July 2017. 


The HSE & Crown Prosecution Services considered a charge of Corporate Manslaughter but accepted a plea of guilty for breaching s.3(1) of the Health and Safety at Work Act by failing to carry out a risk assessment and properly maintain the hot tub.


Twenty others were also affected after a hot tub on display at JTF warehouse in Stoke-on-Trent exposed people to harmful levels of Legionella bacteria.  Stafford Crown Court heard that there should have been better maintenance of the hot tub and a more thorough risk assessment.


After the sentencing, JTF apologised "unreservedly" for its failings that had such "devastating consequences".  Since the deaths, a new board of directors and senior management team had been appointed at the company, it said.  "A rigorous and extensive review of the company's health and safety controls, management procedures and risk assessments has been completed."

G4S fined £1,800,000 by Chelmsford Crown Court for Legionella failings plus costs of £34,000 - Sept 2016


G4S pleaded guilty to breaching sectionss 2(1) and 3(1) of the Health and Safety at Work Act.  In October 2013, a G4S worker was reported to have contracted Legionnaires’ disease, which causes flu-like symptoms and can, in some cases, lead to life-threatening problems.


Harlow Council investigated but environmental health officers were unable to prove that the worker had contracted the disease from the site.  However, the council did uncover a serious lack of compliance in maintaining water systems at the workplace.


At Chelmsford Crown Court on 2nd Sept, Judge Emma Peters decided the company’s culpability was very high because of its “flagrant disregard for the law”.  The judge set the fine at £2,700,000, which was reduced to £1,800,000 when the company’s guilty plea and mitigation were considered.  It was given 28 days to pay the fine plus Harlow Council’s costs of £34,000.


The Court of Appeal rejected the company’s argument that its culpability was wrongly categorised as “very high” during sentencing, and that the fine was therefore “manifestly excessive”.

RUH NHS Trust Bath fined £300,000 by Bristol Crown Court for Legionella related death plus costs of over £35,000 - April 2018

Colchester Hotel prosecuted in Chelmsford Magistrates Court for Health & Safety failures including Legionella - March 2018

Cheetham Hill Nursing Home in special measures after the CQC finds care breaches including Legionella failings - Jan 2018

Bournemouth GP rated “Inadequate” and patients at “risk of harm” for safety failures including Legionella - April 2017

Reading Borough Council fined £100,000 by Reading Crown Court for Legionella failings plus costs of £20,000 - Jan 2016

Council Architect Cleared of Manslaughter but Found Guilty of Breaching Health & Safety Law after Legionella Deaths – July 2006

Five companies face charges under the Health & Safety at Work Act following a Legionella outbreak in Scotland - Dec 2017

Dudley Engineering Firm fined £10,000 by Wolverhampton Magistrate’s plus costs for Legionella Failings - Nov 2017

Dewsbury Care Home put in special measure by the CQC for Legionella failures and given 6 months to improve - Nov 2017

Tendring Council forced to move residents out of Sheltered Housing Complex because of risk of Legionella - Oct 2017

Hereford Medical Centre order to improve patient safety by the CQC after Legionella failures were found – May 2017

CQC orders “Inadequate” Teesside Dentist to improve after they failed to implement Legionella control & prevention - Jan 2017

Cider maker HP Bulmer and its water treatment contractor Nalco have each been fined £300,000 by Hereford Crown Court over a fatal outbreak of Legionnaires' disease – July 2008

Burton Hotel forced to close by Public Health England after Legionella bacteria found in the plumbing systems - Oct 2017

Trafford Care Home rated “inadequate” by CQC for the second time for putting residents at risk of catching Legionella - Sept 2017

Ashby Doctors Surgery put in special measures by the CQC for Legionella failures including staff training - Aug 2017

Bromley GP Surgery rated “Inadequate” and placed in special measures are Legionella related failures - May 2017

South Reading Surgery rated as “Inadequate” by the CQC after they failed to put a Legionella Risk Assessment in place - Mar 2017

Two West Midlands firms have been fined £120,000 each by Wolverhampton Crown Court after staff and the public were put at risk of exposure to legionella – June 2011

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