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    HOSPITAL FINED FOR LEGIONELLA DEATHS & WINDOW RISK

    Foundation Trust sentenced after two separate building maintenance blunders

    Basildon and Thurrock University Hospitals NHS Foundation Trust has been ordered to pay a total of £350,000 in fines and costs for serious safety failings relating to two separate matters.

    The first prosecution concerned control of legionella in the water system after some seven patients became infected with legionella, the bacteria that causes Legionnaires’ Disease. Raymond Cackett (aged 54) died in March 2010 as a direct result of developing Legionnaires’ Disease and the disease also contributed to the death of 74-year-old patient James Compton in June 2007. A further five patients were infected at the hospital between 2006 and 2010, as was a hospital visitor.

    Chelmsford Crown Court heard (3rd Sept) that HSE identified a “catalogue of failures” including failure to monitor the hot and cold water systems adequately or ensure that key parts of the system, such as the shower heads and hoses, were kept clean.

    Numerous warnings from regulators and consultants not heeded

    Basildon and Thurrock University Hospitals NHS Foundation Trust was (4 September) fined £100,000 with costs of £162,000 after admitting breaching Section 3(1) of the Health and Safety at Work etc Act 1974 for the period between 28 February 2004 and 31 December 2010 in relation to the legionella cases.

    HSE inspector Susan Matthews said:

    “People being treated in hospitals are especially susceptible to infection. That is what makes these failings in legionella management all the more concerning. Not only did two families suffer the loss of their loved ones, six people suffered serious illness due to developing this potentially fatal form of pneumonia.

    Healthcare providers, like all organisations, have a legal duty to control the risks by properly maintaining hot and cold water systems.

    The Trust received numerous warnings from regulators, and consultants brought in to give the hospital advice and support, but these were not fully heeded. The Trust also failed to learn lessons from a previous prosecution after a death in 2002, despite having recognised that systems in place were not appropriate to protect the health and safety of its patients and visitors.”

    The Care Quality Commission (CQC) will now continue to monitor the Trust, including further unannounced inspections, and will “not hesitate to take action where we find standards have fallen short of what people should be able to expect.”

    No clear policy on window risks and responsibility for safety checks

    The Trust was also sentenced for separate proceedings relating to a fall from a window.

    The Court was told that an elderly woman was found outside Basildon and Thurrock Hospital’s Horndon ward by two security guards on the evening on 23 June 2012. The patient should have been in her room in the Marjorie Warren ward in the Jubilee wing. The woman had Alzheimer’s disease and had been admitted to Basildon hospital for safeguarding.

    HSE identified failings relating to ineffective window restrictors:

    • Assessment – NHS guidance (in place since 1989) required a risk assessment and window safety policy to ensure no window other than those on the ground floor should open by more than 10 centimetres. The Trust did not have a clear policy identifying the risks associated with windows and employees who were expected to undertake window safety checks had received no training or instruction on how to carry out their duties correctly; and
    • Restrictors – as a result, the restrictor on the window in the elderly patient’s room was inadequate. The window could be opened by more than 10 centimetres and she was able to climb out. She is now barely able to walk, despite having been physically fit prior to the incident.

    Basildon and Thurrock University Hospitals NHS Foundation Trust pleaded guilty to breaching Regulation 3(1) of the Health and Safety at Work etc Act 1974 for this incident. It was fined a further £75,000 with additional costs of £13,000

    Afterwards HSE inspector Corinne Godfrey said:

    “Incidents such as this are wholly preventable. Had a suitable window safety policy been in place, this elderly woman, who was known to have a form of dementia, would not have been able to open the window wide enough to fall out.

    Every year vulnerable people are killed or severely injured in falls from windows in health and social care settings. Health and social care providers have a duty to ensure that they have a robust safety management system in place for windows, and that those tasked to undertake safety checks on key items such as window restrictors have had adequate training to do so.”

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