Failures at council made Barrow outbreak possible

News | HSW
01.06.2007

Barrow Borough Council's failure to carry out Legionella risk assessments and to appoint a "responsible person" to monitor its air-conditioning system, combined with badly drafted and managed contracts and a lack of interest by senior management in health and safety issues, were the systemic failures that led to the Legionnaire's outbreak that killed seven people in 2002.

These are the conclusions of the HSE's report on the public meetings held in the town last December to explain the outbreak's causes to the town's people.

The report also details the individual errors and mismanagement that led to the UK's largest Legionella outbreak, which infected at least 180 people after cooling towers for the air-conditioning plant in the council's Forum 28 arts centre sprayed infected water drops into an alley beside the centre. These shortcomings led to the prosecution of a manager, Gillian Beckingham, for manslaughter and a health and safety offence, though she was only convicted on the latter count, along with the authority itself.

Transcription error

The cooling system in Forum 28 was maintained adequately between the early 1990s and 2000, when the council changed contractors for the heating and ventilation maintenance.

Negotiations with the replacement contractor, Interserve, were handled by the council's Design Services Group (DSG), which had appointed the previous contractors. As DSG manager, Gillian Beckingham led the negotiations. At the time of the contract specification there were changes expected to the HSE's guidance on one form of biological monitoring. Uncertainty on this point led Beckingham to note in a contract meeting "checking/dosing to be omitted". Instead of suspending just the biological testing, this instruction, which was carried over into the new service contract, meant Interserve took no responsibility for refilling the drums of chemical biocide that kept the water that circulated in the chillers and cooling towers free of bacteria, or for any monitoring. The HSE estimated that supplies in the drums must have run out around December 2001, some eight months before the first case of Legionnaire's disease was diagnosed.

In 2001, the HSE sent new statutory guidance on Legionella control (L8 Legionnaire's Disease - The Control of Legionella Bacteria in Water Systems) to the council along with all other registered owners of systems of the type at Forum 28. The guidance was filed away by the officer who received it and was never distributed. Subsequently, an HSE questionnaire on the state of the cooling system was left incomplete and not returned to the executive. Beckingham also ignored two alerts from one of Interserve's engineers that the system was potentially unsafe.

The report says the individual failings of council staff or the contractors are less instructive than the systemic problems in the council's contract and risk management. It emphasises the lack of supervision of the terms and performance of the maintenance contract. "Leaders should be aware of what areas of work are contracted out and acknowledge and provide input into the substantial contracts," the HSE report argues.

No one watching

Cross-questioned at the public meeting, Barrow council's leader Tom Campbell admitted that whether a contract was considered "substantial" (and so double-checked by senior management) depended on cost rather than any associated safety risk.

"The council, like most councils, has a hierarchy for decision-making, usually based on the value of the works," said Campbell. "So we have certain works that are below a certain value and they are delegated down."

He also agreed with the HSE's finding that the council did not meet its duty (under the Management of Health and Safety at Work Regulations) to carry out risk assessments for many activities even after external auditors had pointed out failings in this area.

"Certainly if I personally had taken a much firmer approach to insisting that risk assessments were completed rigorously within a tighter timescale that may well have thrown up the issue of the air-conditioning system," he conceded.

The HSE's report draws attention to the fact the council had not appointed a "responsible person" to ensure there was an up-to-date risk assessment for the air-conditioning system and that the dosing and testing regime was adequate. "An appointment of this kind would have breached the communication gap between Forum 28 and leaders and prevented the outbreak from occurring," say the report's authors. 

Campbell said that, since the outbreak, Forum 28 operates "quite successfully" without air conditioning, removing the hazard altogether. The council also now has a 20-strong group drawn from all parts of the authority, reviewing new risk assessments and calling in existing ones to check they are fit for purpose.

The full report of the public meetings is at www.hse.gov.uk/legionnaires/barrowreport.pdf