Report of the public meetings into the legionella outbreak ...

1 Health and Safety Executive Report of the public meetings into the legionella outbreak in barrow -in- furness , August 2002. Report of the public meetings into the legionella outbreak in barrow -in- furness , August 2002. Health and Safety Executive Report of the public meetings into the legionella outbreak in barrow -in- furness , August 2002. Contents Foreword ii Background 1. Introduction 1. Part 1 Factual Report 2. Background to the disease and organisms 2. Natural history of the legionella bacterium 3.

2 Legal requirements 3. barrow outbreak 4. Site, plant and process 5. System description 6. Serviceability at the time of the outbreak 9. Investigation 9. Summary findings 11. What went wrong? 12. Legal proceedings 13. Corporate Manslaughter and Corporate Homicide Bill 15. HSE's re-engagement with barrow Borough Council 16. Looking forward 18. Remedial action by barrow Borough Council 19. Part 2 Questions and answers 22. meeting 1 22. meeting 2 34. Part 3 Conclusion and recommendations 46. Failure 1: Poor lines of communication and unclear lines of responsibility 46.

3 Failure 2: Failure to act on advice and concerns raised 47. Failure 3: Failure to carry out risk assessments 47. Failure 4: Poor management of contractors and contract documentation 48. Failure 5: Inadequate training and resources 49. Failure 6: Individual failings 49. Appendix 1 Legislation 51. Appendix 2 The Honourable Mr Justice S Burnton's sentencing remarks 52. Appendix 3 Joyce Edmond-Smith's letter to Council leaders 55. References and further information 57. Cover photograph is courtesy of Figure 3 is courtesy of Virtual Reconstructions Ltd Report of the public meetings into the legionella outbreak in barrow -in- furness , August 2002.

4 Foreword On the initiative of barrow MP, the Rt Hon John Hutton, HSE organised hearings into the barrow legionella tragedy. This was done in the aftermath of the trials of barrow Borough Council and Ms Beckingham and, for obvious reasons, could not have been undertaken earlier. I accepted HSE's request for me to chair the hearings. In no way could we, as it were, conduct another trial. But of course, the findings of the Courts were a baseline for our work. We were somewhat restricted in that we had to take care not to prejudice any disciplinary and investigatory inquiries barrow Council has still to undertake.

5 While we had no statutory powers and therefore no authority to summon' witnesses to attend, it was gratifying that everyone we asked to give evidence volunteered to do so. As well as those who gave presentations or made other contributions, the Cumbria Police, the local Health Trust and a senior Councillor representative attended. Though emotions throughout were high, the self-restraint and courtesy of those present, many of whom had suffered bereavement in the legionella outbreak and had waited many years for the opportunity to have their concerns addressed, was remarkable.

6 This was despite a long-running quest for culprits' by sections of the public and strident demands for resignations and sackings that generated much heat but little light. The purpose of the hearings was to cast as much light as possible on the circumstances up to, during and after the outbreak , and to encourage those local citizens most affected to probe into the story, seeking the answers they had hitherto not secured. It was also most important that we should produce a Report that would be useful in helping not only barrow , but also other local authorities and other relevant organisations, avoid any repetition through negligence, mismanagement or ignorance, of barrow 's tragedy.

7 Several awful flaws were apparent from the start. The negligence of the Council in respect of the Forum 28 cooling towers over a long period of time and its lack of systems of control over such risks was dramatically summarised by the trial judge. It was important to us that the lessons learned by the Council, Councillors, officers, staff and unions be made crystal clear. While other public agencies involved reacted well once the outbreak was spotted, there are still areas, which are addressed in the recommendations, where procedures should be tightened, perhaps to the point of hyper-precaution, not least by strict adherence to readily available guidelines such as Legionnaires' disease.

8 The control of legionella bacteria in water systems. Approved Code of Practice and guidance ( L8').1. The following Report seeks therefore, in the first instance, to address the long-standing and deep concerns of the people of barrow and their natural anxieties at the lethal outbreak of disease in their midst. We have sought to Report as clearly and accurately as possible (despite acute difficulties with the audio-recording of the proceedings). We have sought also to make clear and practical recommendations so that some good may come out of tragedy.

9 We are indebted to the administrator of the hearings, Tania van Rixtel, whose tireless work, especially in deciphering the recordings of the proceedings, has been crucial to producing this Report . Colin Pickthall Chairman of barrow public hearing ii Report of the public meetings into the legionella outbreak in barrow -in- furness , August 2002. Background 1 In August 2002, seven members of the public died and 180 people suffered ill health as a result of an outbreak of legionella at a council-owned arts and leisure facility in the town centre of barrow -in- furness , Cumbria.

10 Like most accidents, this tragedy could have been avoided, if the risks had been properly managed. 2 We would like to remember those who tragically lost their lives as a result of the outbreak . Richard Macauley (89), Wendy Milburn (56), Georgina Sommerville (54), Harriet Low (74), Elizabeth Dixon (80), June Miles (56) and Christina Merewood (55). 3 This Report follows two public meetings , organised by the Health and Safety Executive (HSE), to explain to the people of barrow and others what happened that summer.