Scots health board fined over patient illness

The 64-year-old caught the disease at Hartwoodhill Hospital

A SCOTS health board has been fined £24,000 after a patient contracted a deadly disease.

The 64-year old female patient was being treated atHartwoodhillHospital, which is run by NHS Lanarkshire, when she became gravely unwell.

She was admitted toWishaw GeneralHospital, where it was discovered that she was suffering from pneumonia and severe sepsis and was diagnosed as having Legionnaires’ Disease.

She was treated with intravenous antibiotics, but medics were forced to perform a tracheotomy to help her breathe on 1 December 2008.  She returned to Hartwoodhill Hospital on 23 December.

An investigation by the Health and Safety Executive (“HSE”) identified that legionella bacteria was present in three sources in the water system at the hospital.

Two of those sources, including the shower used by the patient on a daily basis, matched the strain of legionella bacteria that had caused her illness.

The HSE investigation also established that a suitable and sufficient assessment of the risks from the potential presence of legionella bacteria to persons using the facilities had not been carried out, nor was there a safe scheme in place to manage and control the risks of exposure to that form of bacteria in the water system at Hartwoodhill Hospital.

At the time of the discovery of the legionella bacteria, the premises were in the midst of a demolition programme, which had the potential to disrupt the water system.

Fewer patients were in the hospital resulting in reduced demand on the water supply and the demolition work would have increased the possibility of dirt and debris, which would provide a source of nutrients for the bacteria getting into the system.

Both of these factors would have increased the overall risk of the system and should have triggered a review of any assessment in order to decide whether any additional measures would be required to maintain control of water quality.

Following the case, Elaine Taylor, Head of the Crown Office and Procurator Fiscal Service Health and Safety Division, said: “Over a significant period of time there was no suitable and sufficient assessment or management of the risks of there being legionella bacteria at Hartwoodhill.  This resulted in members of the public, including patients who were relying on the hospital for their care, to be exposed to a risk from the bacteria.  For one lady that exposure resulted in her contracting Legionnaires’ disease, becoming very unwell and requiring surgery.  The events were entirely avoidable.

“It is vital that there is proper and effective management of water systems when the potential presence of legionella bacteria is a risk.

“Legionnaires’ disease is a very dangerous illness and those who fail to manage their systems adequately and expose persons to risk of contracting it, whether private companies or bodies such as Health Boards, can expect to be prosecuted.”

HSE Inspector Mike Orr said: “This investigation highlights the importance of having robust management arrangements in place to ensure that the risk from legionella is controlled. This is particularly important where potentially vulnerable groups, such as patients in hospitals, are at risk.

“Responsibility for implementing the arrangements should be assigned to a competent senior manager and the effectiveness of the arrangements should be subject to monitoring.”