Lessons to be learned Part 2

Another article in the occasional series on lessons to be learnt from my role as an Expert Witness and consultant.

Causation expert witness

This article is a follows up on one I wrote a year ago and is based on more cases and sites I have been involved with. The first article covered issues that many sites do not pay enough attention to, this included the lack of or an inappropriate Responsible Person, an incomplete Written Scheme, ongoing monitoring and interpretation of results and remedial actions.

This article covers other areas that I have regularly come across starting with:

Lack of training

I often read in risk assessments that on-site staff have not been trained or the training is more than three years old. In today’s age of computers and online training there is no excuse for sites to have staff that aren’t trained with regards to Legionella management. On-site training is not expensive when you compare it against the likely fines for not carrying it out and online training is even more cost-effective.

Training should be relevant to the tasks being undertaken so somebody measuring temperatures does not necessarily need the full Legionella training, whereas basic awareness training may not be suitable for a Responsible Person, depending on the complexity of the site.

I, like many other providers, offer both bespoke and online training, so there are plenty of providers out there, the trick is to find one that understands the issues and can meet your unique needs.

Quality of risk assessments

Unfortunately, this can still be an area of concern. BS8580 covers carrying out Legionella risk assessments and many if not all risk assessments in the UK claim to follow its recommendations. This document is being updated currently and will be released at the end of 2018, so it will be interesting to see if risk assessors take more note of the new standard. Current risk assessments often contain many pages of standard text lifted out of L8 and HSG 274 documents, so they have the feel of not being bespoke to site. This is someting that is addressed in the draft version of BS8580 rewrite.

Some also make it difficult to understand the algorithm used for deciding the level of risk. Remember risk is a two factored issue with the likelihood of the event occurring matched against the severity of harm if it does happen. Once the level risk is decided the recommendations should naturally follow on, which is where some risk assessments fail. They do not consider the HSE guidance of elimination, substitution, control at source or use of procedures to control the risk. Consequently, you find recommendations that do not meet the “suitable and sufficient” criteria.

Whilst the HSE recognise that there is no legal definition of “suitable and sufficient” there are several other tools that can and should be used to determine whether the risk assessment is “suitable and sufficient”. Having a logical risk assessment that is straight forward to follow could be one of these criteria.

Written scheme

Last time I wrote about a poor or incomplete written scheme however there are still sites that do not have a written scheme despite it being clearly mandated in L8 with guidance as to what it should include in HSG 274.

It can be a complex task to write a written scheme but there are resources available to sites to enable them to have a compliant written scheme. For example, I spend quite a bit of time writing written schemes for sites, so help is available.

The HSE often look to prosecute sites for lack of Legionella management systems and this can be a major part of the Legionella management system on site so it is important a) to have one and b) to make sure it matches the advice in HSG 274.

Misquoting standards

Unfortunately, as an Expert Witness this is something I see all too often. The most common mistake I see is that cooling towers or cold water storage tanks have been cleaned to meet the standards described in L8.

What does L8 have to say about the standard for cleaning and disinfecting cooling towers or cold water storage tanks? Nothing, other than to say that the written scheme should give details on how to use and carry out the various control strategies, one of which is cleaning and disinfection procedures.

So please do not put on your cleaning and disinfection certificates that the clean meets the standards of L8.

Another example, still seen, is that a clean was carried out in compliance with BS6700, even though on publication of parts 1 to 5 of BS EN 806, BS 6700:2006+A1:2009 was withdrawn.


Attention needs to be paid to the details of your Legionella management scheme as it is here that you can let yourself down which can possibly lead to HSE action of some (unwelcome) kind.

If you are concerned about the completeness of your Legionella management scheme then contact Collaton Consultancy for help and advice before the HSE come knocking.

Is Legionella training expensive?

A UK based private health firm has been fined £3 million after the death of a resident at one of their care homes from Legionnaires’ disease.

When investigated by the HSE they found that for more than a year whilst major refurbishment works were carried out the company failed to implement the necessary control and monitoring measures under ACoP L8 and HSG 274 to safely manage their hot and cold water system. Further, those responsible for overseeing legionella controls and for taking water temperature measurements had not been trained to the required standard.

The company pleaded guilty and were fined £3 million plus £151k costs.

Had the company had the right level of training they might have avoided the death of one of their residents and the resulting fine.

Online training

I think you’ll agree that a lack of Legionella training has proved very expensive to this company,  both financially and reputationally.

If you want to avoid this expense and invest in some quality Legionella training then contact Collaton Consultancy Limited, we offer bespoke on-site training as well as on-line video based training.

Contact us on general@collatonconsultancy.com or phone on +44(0)7958 124563 to discuss your specific needs.

How to prevent Legionnaires’ disease

Legionnaires’ disease is an illness caused by breathing in an infected aerosol containing Legionella bacteria. This can either be from water or soil, so buildings containing water systems (cooling towers, spa pools, hot and cold water are common sources), or garden compost and soils, are all likely sources to be aware of.

cooling towers 1

Once you have identified your potential sources then you need to carry out a risk assessment, which the UK’s Health & Safety Executive require to be “suitable and sufficient”. This risk assessment needs to identify all potential sources of risk, identify potential ways of reducing that risk (to levels deemed ALARP, see a previous post on this subject) and to provide a prioritised list of action points.

Once the risks have been identified you can then create a written scheme which identifies the maintenance tasks required to minimise the risks. This could involve removing the risk completely, for example changing a water based cooling tower to an air blast chiller or removing sinks that are no longer required, or producing a series of tasks to be carried out regularly to minimise the risks.

A list of essential tasks to carry out are described in the UK’s HSG274 which provides detailed information and guidance for cooling towers, hot and cold water systems, and other risk systems. This guidance is not an exhaustive list so you may need to look at your system and ask yourself when are the specific risks created and how can I protect humans who come into contact with the source.

hot tub

If you have a spa pool then also consider HSG282 which provides guidance specifically for spa pools.

The written scheme needs to be comprehensive and contain sufficient detail for you to manage your systems. This should include “what-if” scenarios describing how you would manage foreseeable non-conformances or events.

Don’t forget you may have a list of remedials that come out of your risk assessment so it would be useful to create an action plan checklist of these tasks to ensure you complete all of them in a timely manner. This may involve, for example, fitting point of use filters as a short term expedience whilst you resolve an issue using an engineering solution so be aware of all tasks needed to be completed.

An important part of all of this is to keep records of what has to be done and what has been done, and don’t forget to ensure all tasks are dated and signed as proof of their completion because you never know whn you might need to use these to support you if questioned about what has been done.

If you follow a logical approach to managing Legionella, supported by the available documents, then managing Legionella need not be a chore.

If you need expert help to support you in finding your way through these documents then Collaton Consultancy Limited can help you.

Legionnaires’ disease from potting compost.

Legionnaires’ disease from potting compost is a real issue so do you know what precautions to take, Australia is ahead of the rest of the world in this instance in that they print handling precautions on the bags of compost.

These warnings state:

  • Wear a face mask when handling soil, mulches, compost or growing media indoors or in windy conditions.
  • Open the bag using a blade with care to avoid inhaling airborne growing media, i.e. slowly and away from the face.
  • Moisten the contents of the bag on opening, by making a small opening and inserting a garden hose to dampen the growing media.
  • Avoid potting-up plants in unventilated areas, such as enclosed greenhouses or sheds.
  • Wear gloves.
  • Avoid transferring growing media from hand to mouth (e.g. rubbing face with a soiled hand or glove). Always wash hands after handling growing media, even if gloves have been worn, as Legionella bacteria can remain on hands contaminated by growing media.
  • Store growing media in a cool place, away from the sun.
  • Keep soils and growing media damp.
  • Avoid raising soil near evaporative coolers.
  • Water gardens and composts gently, using a low-pressure hose.
  • When handling bulk quantities of growing media or other soil products, follow procedures that minimise dust generation.

Various research papers point out that whilst the route of transmission to the human host is not fully understood the possibilities include hand-to-mouth, aspiration, or aerosolization.

Interestingly not only are Legionella supported in human and amoebic hosts but it appears that L. longbeachae have been shown to colonize and persist within the intestinal tracts of Caenorhabditis nematodes but did not invade surrounding tissue and were excreted as differentiated forms similar in structure to protozoan cysts. This study suggested that nematodes may serve as natural hosts for Legionella spp. and assist in their propagation throughout soil environments.

The risks associated with using composts and catching Legionnaires’ disease are extremely low, with over a billion bags of compost sold and only 6 cases over the last few years in the UK , but it shows that Legionella is more persistent in the environment than perhaps first thought.