Press Association
Wednesday 22nd February 2012
A health board has been fined £24,000 after an "entirely avoidable" chain of events resulted in a hospital patient being diagnosed with Legionnaires' disease, the Crown Office has said.
Lanarkshire Health Board admitted breaching health and safety legislation which meant a 64-year-old woman contracted the disease at Hartwoodhill hospital in November 2008. The health board was fined the sum at a hearing at Hamilton Sheriff Court for breaching Section 3 of the Health and Safety at Work etc Act 1974.
Prosecutors said the patient had been admitted to Wishaw General Hospital after becoming "gravely unwell" at Hartwoodhill. It was discovered she was suffering from pneumonia and severe sepsis and was diagnosed as having Legionnaires' disease.
She was treated with intravenous antibiotics but underwent a tracheotomy on December 1 2008, returning to Hartwoodhill on December 23.
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 found that a "suitable and sufficient assessment" of the risks from the potential presence of legionella bacteria to people using the facilities had not been carried out. It said there was no safe scheme in place to manage and control the risks of exposure to the bacteria in the water system at Hartwoodhill.
Elaine Taylor, head of the Health and Safety Division at Crown Office and Procurator Fiscal Service, 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."
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."
An NHS Lanarkshire spokesman said: "We deeply regret the occurrence of this lapse in legionella management from our generally very high standards of health and safety management. We have unreservedly apologised to the family and have given an assurance that lessons have been learned."
