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Hazards 119, July-September 2012
Outbreak. Legionnaires’ deaths expose bugs in HSE system
The Health and Safety Executive (HSE) is telling businesses to do more
to protect workers and members of the public from Legionnaires’ disease, but at the same time is doing less and less itself.

The Health and Safety Executive (HSE) urged businesses to do more to prevent Legionnaires’ disease in a Safety Notice released a day ahead of the death of Richard Griffin, 64, who succumbed to multiple organ failure on 28 July 2012. He was the first victim of a Legionnaires’ disease outbreak in Stoke-on-Trent, the second outbreak of the summer. His family said the delivery driver had not taken a single day off work sick in 30 years. He delivered goods to JTF Warehouse, the store believed to be the source of the infection. On 17 August, the outbreak was declared over, but by then had claimed a second life and affected 21 people.

TOWERING INDIFFERENCE  Safety watchdog HSE is far less likely to be seen inside a cooling tower these days. Airborne water droplets from the towers are a top culprit in Legionnaires’ disease outbreaks.

An earlier outbreak in Edinburgh, which had its first case identified on 28 May 2012 and subsequently claimed three lives and infected over 100, was declared over on 18 July. Lothian and Borders Police and HSE are investigating the circumstances of the deaths under the direction of the Crown Office and Procurator Fiscal Service (COPFS) Health and Safety Division.

The Edinburgh cases are believed to be linked to local cooling towers. On 8 June, North British Distillery Company Ltd had an improvement notice served by HSE on one cooling tower, although the company chose at the time to take all three cooling towers out of operation. On 11 June, HSE issued an improvement notice requiring Macfarlan Smith Ltd to undertake thorough cleaning of one of its cooling towers and to provide access for inspection and maintenance. Neither firm was linked directly by HSE to the cases of Legionnaires’ disease.

Launching its safety notice, HSE said it had identified common failings in legionella control from a review of outbreaks of Legionnaires’ disease in Great Britain over the past 10 years. The research showed 90 per cent of outbreaks stem from failure to recognise potential legionella problems or to adopt effective control measures. The notice also stressed the need for effective and consistent monitoring of water quality and the importance of responsibilities being assigned to named individuals with proper management oversight.


Inspection prevents infection

But HSE’s oversight itself has been called into question, after an investigation launched in the wake of the Edinburgh outbreak exposed reductions in the number of legionella inspections carried out by HSE.

The probe by the Chartered Institute of Environmental Health’s (CIEH) magazine, EHN, found the number of proactive HSE inspections for legionella – the bacteria responsible for the disease - across the UK fell from 833 in 2009 to 464 in 2011, a drop of 44 per cent. The number of legionella inspections at cooling towers fell from 237 in 2010 to 134 in 2011. HSE said there were around 5,800 notified cooling sites in the UK, of which an estimated 2,900 undergo inspections by HSE rather than the local authority.

Leading bacteriologist Prof Hugh Pennington commented: “It shows a highly unsatisfactory state of affairs. The great majority of cooling towers can only be having inspections once every ten years, some probably less frequently, and the number of inspections fell significantly in 2011. Coupled with the Edinburgh outbreak, these statistics indicate the need for a root and branch review of Legionnaires’ regulatory policy. After all, it is a preventable disease but one with a significant mortality.”

Launching HSE’s safety notice, the safety watchdog’s Paul McDermott said those responsible for the maintenance of water systems “have a responsibility to manage the risks they create to protect workers and the wider public. This is a reminder to them of what the law expects. Failure to comply with the law means they may face legal sanctions, including in the most serious cases prosecution through the courts.”

HSE chief executive Geoffrey Podger continued the ‘not us, guv’ theme in a 19 August letter to The Guardian. He said: “It is indeed tragic that illness and deaths are seemingly occurring as a result of failure to observe well-established precautions that are a legal obligation on those who run the businesses concerned.”

But he added “there is no correlation between outbreaks of legionella and the number of inspections carried out by the regulators. The latter are a valuable part of our overall approach to highlighting this problem, but can be no substitute for the appropriate measures being taken on sites day in, day out by those with the legal responsibility.”

Others are concerned HSE is adopting far too passive a role. CIEH chief executive Graham Jukes commented: “Health and safety regulation is there for a purpose and either resources should be made available to increase the awareness of businesses to their primary responsibility or to increase the inspection resource,” he said.

“Failure to do either will result in further tragedy that could be prevented.”


Deaths are a ‘stark reminder’

Prospect, the union representing Health and Safety Executive (HSE) inspectors and specialists says the recent cases of Legionnaires’ disease are a stark reminder that cuts to public services can create dangerous and ultimately expensive health-related problems in the longer term.

Prospect points out that as a result of a ministerial instruction, the government's safety regulator has reduced the number of preventive workplace inspections by one-third, down from 30,000 to 20,000 a year.

Negotiations officer Michael Macdonald said: “In order to ‘reduce the burdens on business’ HSE field inspectors’ primary focus is now on reactive investigations that respond to known incidents. Whole sectors of industry have now been explicitly exempted from proactive inspections.” He said the Legionnaires’ tragedy “highlights the risks to society of diminished proactive inspections.”

Simon Hester, Prospect’s HSE branch chair, said it “is a stark reminder of the danger of denigrating health and safety at work and the value of effective inspection by the HSE. Due to spending cuts, HSE’s occupational health expertise is extremely thinly spread, which has led to a lack of sufficient advice in the field. Cooling towers are common in many industrial processes and the risks created by poor health and safety management are well known.”

He added: “It is always preferable to avoid incidents that harm people, rather than merely investigating after the event, so Prospect believes that decisions on proactive inspection should be based on professional expertise and that adequate resources are made available. HSE needs more inspectors, not less.”

The union points out that the government has exempted from proactive workplace inspections the whole of the public sector including health, education, prisons and emergency services; public transport including buses and airports; the post office and parcels delivery; agriculture, docks, electricity generation; and manufacturing industries including light engineering, plastics and rubber, printing and electrical engineering.

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The Health and Safety Executive (HSE) is telling businesses to do more to protect workers and members of the public from Legionnaires’ disease, but at the same time is doing less and less itself.


Towering indifference
Inspection prevents infection
Deaths are a ‘stark reminder’

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