Kulwant Singh Chatha and Satpaul Kaur Chatha pleaded guilty to breaching section 2(1) and 3(1) of the Health and Safety at Work etc Act 1974 and were each sentenced to serve 12 weeks in prison, suspended for 12 months, and ordered to pay costs of £12,115 each, including a victim surcharge of £115.
Birmingham Magistrates’ Court heard that, between June 2017 and February 2018, Kulwant Singh Chatha and partner Satpaul Kaur Chatha of Isher Hangers failed to put suitable measures in place to control the risk of Legionella bacteria from the cooling tower on their premises. Concerns raised by their own water treatment consultants were ignored, and no Legionella risk assessments were in place.
Andy Clegg, who lived at Fordingbridge Care Home, was admitted to Salisbury District Hospital in October 2017 and died nearly two weeks later. An inquest jury ruled that the 56-year-old contracted Legionella pneumonia while at the home. Assistant coroner Nicholas Rheinberg said he would contact the Care Quality Commission, which regulates the industry, and ask it to review the training given to water safety inspectors. He will also urge the Royal Institute of British Architects to take any necessary action to reduce the risk of Legionella bacteria in care homes. Mr Clegg moved to Fordingbridge Care Home, run by Sentinel Healthcare, almost two years ago.
In a statement issued after the inquest his brother and sister, Joanne Denyer and Matt Clegg, said: “Andy was a loving and generous soul and the pain and suffering he experienced in the days before he died remains with us. “The last few days have been incredibly difficult, but we were determined to honour Andy’s memory by obtaining the answers he deserved. “We entrusted Sentinel to look after Andy, but our family find it difficult not to think we were let down with terrible consequences. “All we can hope for now is that his death was not totally in vain and reinforces how dangerous Legionnaires' can be. It's vital that businesses and public bodies ensure they take all necessary steps to prevent others contracting the disease.”
The family were represented at the Salisbury inquest by specialist lawyers from Irwin Mitchell. Speaking immediately after the four-day hearing Jatinder Paul, a senior associate at the firm, said: "Andy’s death has had a profound effect on his family. "For the last 16 months they have had a number of concerns which have been ignored by Sentinel until today, when they finally accepted that Andy contracted Legionnaires’ disease at the Fordingbridge Care Home and this ultimately caused his untimely death. “Whilst nothing can ever make up for Andy’s death, we are pleased the hearing has helped answer the family’s concerns.
"We are pleased the coroner will now write to the Care Quality Commission to raise his concerns that more needs to be done for the training of inspectors in water safety to prevent future deaths from Legionnaires’ disease in the care setting. “The coroner has also announced his intention to write to the Royal Institute of British Architects to consider the layout and design of buildings in the care setting."
A council has been fined £27,000 after a deadly bacteria outbreak at one of its leisure centres nearly killed a resident. At Colchester Magistrates’ Court Tendring Council admitted breaching health and safety legislation after a Legionella outbreak at Walton Leisure Centre in 2016.
Pensioner Graham Leach, then 68, was lucky to escape alive after contracting Legionnaire’s disease and the council’s procedures for preventing outbreaks were found to be outdated at Walton, Clacton and Dovercourt leisure facilities. Matthew Taylor, prosecuting on behalf of the Health and Safety Executive, said the council’s procedures were not up to scratch for detecting the bacteria. He said: “The council’s reports lacked detail and did not contain information they should have contained. “The investigation found there were times when temperature controls noted a problem, but no one was competent enough to identify there was a problem or pass it up the chain. He added: “You would absolutely expect the council to be familiar with the risks of Legionella in water systems and know how to deal with stopping the risks.”
The council says it has spent £190,000 on a comprehensive review at not only its leisure centres, but its offices, since the outbreak. Deanna Heer, mitigating, expressed sincere apologies on behalf of the council to residents for what happened. She said: “The council did take some steps to minimise the risk. However, the approach of the council led to the result of the outbreak, which was caused by an overestimation of those who were managing the risk and an underestimation of what was required to manage that risk.”
District Judge Woollard ordered the council to pay a fine of £27,000 and costs of £7,194.19. He said this amount would have been ten times as high if the taxpayer were not the ones footing the bill.
Four Seasons Healthcare has been fined £600,000 for safety breaches after a 90-year-old care home resident died from Legionnaires disease. John Bonser died at Kestrel Lodge on 15 November 2012 after contracting the disease, which is contracted through breathing in bacteria carried in water.
In making his ruling at Nottingham Crown Court, Judge Stuart Rafferty QC said that pressures in health and care funding were no excuse for the company failing to discharge its fundamental purpose of keeping residents safe over a significant period of time.
Prosecuting for Ashfield District Council, Bernard Thorogood told the Court that Mr Bonser became a resident at the home in August 2012. He was admitted to Kings Mill Hospital on October 29th 2012 with Legionnaires disease. Cllr Jason Zadrozny, Leader of Ashfield District Council, said: “The Council have worked hard to bring this prosecution to court, and will continue to prosecute those that fail to meet legal standards.”
A Four Seasons spokesperson said: “We deeply regret the death of Mr Bonser, which occurred in 2012, as a result of contracting a Legionella infection while living at Kestrel Lodge. “We accept that there were repeated failures to manage the implementation of procedures to safeguard people in the home, for which we sincerely apologise. “The home had engaged a specialist environmental services contactor to maintain the water systems and keep them free from bacteria, but we should have carried out checks to establish their level of technical expertise".
The City of Wolverhampton Council has closed the Ramada Park Hall Hotel and Spa until further notice after legionella bacteria was found in water samples. The Grade II listed 4-star hotel, which has 74 guest rooms, has been told it cannot use its hot and water taps until an inspection is carried out. Legionella organisms are commonly found within water in the natural environment but elevated levels of the bacteria in a water supply can increase the risk of contracting Legionnaires’ disease.
An Andover disability charity has been criticised in a damning report which revealed delayed waiting times for assistance and the risk of infections to residents. Enham Trust Care Home Services received an unannounced inspection from the Care Quality Commission (CQC) from April 10 to 12 which focused on the charity’s three care homes, Michael, Elizabeth and William Houses. Inspectors raised a catalogue of concerns, rating the service as ‘requires improvement’, with four aspects – effectiveness, caring, responsive and well-led receiving the mark. The CQC also revealed low levels of legionella bacteria had been detected in the water system of Elizabeth House in late 2017 and actions had not been taken by February 2018 from the first assessment. And inspectors discovered the service did not have “the right people, with the right qualifications and skills, in post to oversee this area of responsibility”.
Raj Mittal and Steve Stokes, partners at business advisory firm FRP Advisory, were appointed joint administrators to the three AA star, 40-bedroom hotel on 2 August 2018. The administrators said the hotel suffered trading difficulties as a result of the outbreak in 2017 and subsequent investigation by Public Health England. The hotel, which employs 30 people, will remain open for business while options for its future are assessed. No redundancies have yet been made.
Mittal said: "The Feathers Hotel worked closely with Public Health England in the West Midlands and Shropshire to enable a staged reopening of the business. Unfortunately, the impact of the initial closure and restricted trading conditions resulted in severe cash flow difficulties, which led to the company entering administration. We're now working closely with the directors to evaluate all routes forward for the business over the coming weeks."
Elaine Brown, 69, from Merseyside died in August 2017 after suffering a stroke as a result of Legionnaires' disease, just days after she stayed at the hotel with her husband. The historic hotel, which was built in 1619, closed for two months before reopening in November, although two bedrooms and the kitchen remained closed last month after Legionella bacteria was found for a second time. The property was put up for sale for £2.65m in January by the Ceney family who planned to retire having purchased it in 2002.
Both directors behind Bremwell Ltd, the company which operate the Rose and Crown Hotel, in East Street, appeared at Colchester Magistrates’ Court for sentencing. Bremwell Ltd had previously admitted five breaches under the Health and Safety at Work Act. One of the breaches exposed staff and customers to what an independent report claimed was a “trace finding of legionella” - lower than the upper limit of 100cfu/l at 80, back in 2011. The judge said: “The hotel had known for some years there had been an initial infection of legionella and failed to put in place safeguards...there’s no evidence there had been a reinfection, but the steps weren’t there to prevent it.” Mr Withington said: “The directors want me to express their regret for each of these offences and their sincere regret these matters have resulted in criminal proceedings.
A landlord in Lincoln has received a fine of £400,000 after failing to comply with fire, health and safety standards in two of his properties. Mr Bijan Keshmiri was ordered him to pay £404,886.90 in fines and costs for a total of 28 offences in respect of four self-contained flats on Rosemary Lane and a property converted into two self-contained flats on Spa Buildings. It is believed to be one of the biggest financial penalties ever handed out for an individual rogue landlord case in Britain.
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.
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 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.
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 sections 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