EHJ April 2004, pages 110-111
A Cumbrian council was recently charged with manslaughter following a legionnaires' outbreak. Paul O'Day explains how Islington LBC launched an inspection regime to prevent a similar outbreak in the London borough

In August 2002, an outbreak of legionnaires' linked to a council-run sports centre in the Cumbrian town of Barrow-in-Furness, led to seven deaths and 170 people falling ill. In February, Barrow-in-Furness DC was charged with seven counts of manslaughter in connection with the outbreak. The design services manager of the leisure centre was also charged with manslaughter after the fatal bacteria was traced back to the cooling tower in the leisure centre's air conditioning system.

Following this outbreak, Islington LBC decided to inspect all its cooling towers between July and November 2003 to prevent a similar tragedy in its area. EHPs also updated their register of high-risk water systems as a basis for rolling inspections and an education programme for cooling tower managers.

Legionnaires' disease, also known as legionellosis, is a rare form of pneumonia that can be fatal in around 12 per cent of cases. The disease is normally caught by inhaling water aerosol contaminated with the legionella bacteria, deep into the lung. Symptoms are a high fever, chills, headache and muscle pain. Victims may develop a dry cough and suffer difficulty breathing, with about a third of patients developing diarrhoea or vomiting and about a half becoming confused and delirious.

Man-made water systems, such as hot and cold systems in large offices, hotels and factories and cooling systems, provide the ideal conditions for the bacteria to grow, especially if systems are not maintained. Cooling towers were also linked to three legionnaire fatalities in Glastonbury in 1998 and two fatalities in Hereford in 2003.

Islington launched its health and safety project by making telephone contact with premises managers, using contact details originally given to the council. Where contact details were no longer valid, visits were made. This immediately revealed that premises were failing to tell the council of changes, as required by law. Under the Notification of Cooling Towers and Evaporative Condensers Regulations 1992, the council must be notified in writing of any changes on a site within one month of it occurring.

Of the 20 premises on the register, only 16 were still in operation. Six premises had removed their towers without telling the council while two premises had failed to tell the council of the presence of towers. Three premises had not told the council of changes in ownership. Once facilities managers had been contacted, the methodology of the project was similar to that laid out by the Health and Safety Executive in LAC 46/3, (issuing a self audit proforma). All premises were also inspected, with site managers asked to complete an updated notification form.

But to make sure all notifiable devices had been registered, EHPs also sent a letter to local water treatment companies asking them to ensure that their clients had notified Islington of the existence of all their cooling towers or evaporative condensers and that all their contact details were up-to-date.

The study revealed that the majority of the water treatment companies and facilities managers were aware of the risk of a potential legionella outbreak. But despite this, six sites had out-of-date legionella risk assessments, with some referring to HS(G)70 when they should have been using the more recent HSE guidance L8: Legionnaires' disease - the control of legionella bacteria in water systems, approved code of practice and guidance. There was also little evidence that building managers or site owners checked work done by their water treatment company to ensure they were meeting these standards or complying with basic health and safety requirements.

Documents supporting the management and maintenance of the towers often failed to reflect what was really happening on-site. Cleaning and disinfection certificates, legionella sampling, laboratory results, and corrective actions when control parameters were exceeded, were often lacking or incomplete.

Investigating EHPs concluded that if any of these premises had been involved in a legionella outbreak, it would have been extremely difficult for them to demonstrate that they had acted within the scope of the HSE's guidance, laid out in the ACoP.

As for compliance with health and safety law, most premises had failed to assess general risk or risk under the control of substances harmful to health (Coshh) regulations. Most premises managers thought that, by keeping hazard data sheets, they had fulfilled their duties under Coshh. As a result, workers were failing to comply with the Personal Protective Equipment at Work Regulations 1992. Staff information, training and instruction were also poor.

Islington's health and safety campaign confirmed HSE findings, outlined in LAC 46/3, that when premises fail to comply with the HSE's ACoP, it poses a real threat of a legionella outbreak. All the premises in the study either needed to address their legionella control or general health and safety issues. Since completing the project, Islington has produced a set of recommendations (see box 2).

Paul O'Day is the health and safety projects officer at Islington LBC.