Leaked report warns of legionella outbreak

Poor management of cooling towers and evaporative condensers could lead to a ‘catastrophic’ legionella outbreak in London, according to a Health and Safety Executive project report obtained by EHN.

The report, which was commissioned in the run up to the London Olympics, found that 73 per cent of cooling towers and evaporative condensers near Olympic venues and travel hubs in the capital required enforcement notices or advice.

‘The headline to arise from this project is the poor level of compliance,’ it states.

It warns an outbreak in London would be far worse than the legionella outbreak in Edinburgh in June, where over 100 people were infected and three people died.

‘[An outbreak in London] will have catastrophic consequences compared to Edinburgh given it is the area with the most footfall within the country,’ the report states.

An outbreak in Stoke-on-Trent in July linked to a hot tub display led to 21 infections and two deaths.

HSE inspectors found that compliance rates were worse in the public sector than the private sector, with 77 percent of cooling towers and evaporative condensers requiring enforcement notices or advice.

The report points to the widespread outsourcing of facilities management in the public sector and calls for ‘better monitoring’.

‘In many public sector organisations in London, the management of wet cooling towers and evaporative condensers is subcontracted to facilities management companies. It is disappointing that issues have been found at such sites given it is their specialism. This is compounded by the high turnover of facilities management companies,’ says the report.

It says most of the public sector sites visited during the project would not normally be proactively inspected as they are deemed low risk by the government.

‘Most if not all of these public sector organisations […] are deemed low risk. They would not have been subject to a proactive inspection,’ says the report. ‘Given the type of work undertaken, they are unlikely to have appeared on the radar as a poor performer. They would not have been inspected had it not been for the Olympics coming to London.’

Nearly all the sites visited used water treatment companies but the report claims some firms are inadequate.

‘Taken together with the increased turnover of facilities management firms leading to management responsibilities changing it could be speculated that scenarios are occurring where an outbreak could happen,’ the report says.

The report, which was completed in July, calls for the findings of the project to be publicised through trade publications and professional associations. However this did not happen.
The project team identified 106 sites near Olympic venues and travel hubs in London. There were 62 HSE enforced sites and nine sites enforced by councils. There were 31 decommissioned sites and four in embassies where enforcement is a ‘grey area’.

Hugh Pennington, emeritus professor of bacteriology at the University of Aberdeen, told EHN that the report was a 'wake up call' and should have been published.

‘A great pity that the HSE Olympic Project Report has not yet been published. It is a powerful wake-up call for action to rectify the long list of deficiencies found regarding the management of the legionella risk from cooling towers, particularly in the public sector. But for the grace of God there hasn't been an outbreak in London - yet. Urgent action is needed. Legionella kills, but it is preventable,’ he said.

Andrew Watterson, director of the Centre for Public Health and Population Health Research at the University of Stirling, said the government’s distinction between low-risk and high-risk workplaces made little sense.

‘Legionella can present a threat to diverse populations in towns and major cities, the numbers of people who could be affected are very large indeed and the consequences very serious – with both death and serious life-changing illnesses sometimes resulting. With legionella the categorisations of low-risk and high-risk workplaces therefore make little sense,’ he said.
Graham Jukes, CIEH chief executive, said the report painted a worrying picture.

'This report paints a worrying picture about compliance with basic maintenance in the capital especially in the light of recent tragic and high profile legionella outbreaks. In the light of severe public sector resource constraint HSE and local authority EHPs must find more effective ways other than inspection in getting the message out to business that they are responsible for maintaining safe systems of work and for protecting others from harm. It is they who will be held to account for failures and any subsequent tragic consequences,' he said.

The HSE told EHN talk of a catastrophic outbreak was unfounded.

‘This was a comment made by the inspector, who drafted the report, based on speculation and personal opinion. It is not one that is backed up by research or evidence,’ said a spokesperson.

The HSE said formal enforcement action in the form of notices was required at fewer than 10 per cent of the sites visited.

‘Most of this enforcement related to the provision of safe means of access for staff and contractors involved in the monitoring and maintenance of the cooling towers and evaporative condensers, rather than being related directly to legionella management. Verbal and written advice is generally given where it has been identified that improvements can be made and standards raised, but where people are not being put at serious risk,’ said a spokesperson.

The HSE said it was not possible draw any conclusions about the levels of compliance in the public sector as compared with the private sector

‘The inspections in London found some common failings across all sectors in the control of legionella,’ said the spokesperson.

The HSE said research into the outsourcing of facilities management in the public sector was ‘not the purpose of the report’ and claimed ‘there is insufficient information and evidence to draw any conclusions on this issue’.

The HSE said the final report will be made publically available.

‘The final report will be published. Earlier internal drafts were prepared, but as is normal for any publication these have been subject to review, fact checking and further iteration so we can be sure the information published is sufficiently robust and accurate,’ said the spokesperson.

Legionella bacteria, which causes legionnaires’ disease, is found in purpose-built water systems such as cooling towers, evaporative condensers and whirlpool spas. It can grow to dangerous levels in warm conditions and is spread by breathable droplets of water.

Smokers, heavy drinkers and anyone with an impaired immune system or respiratory disease are at particular risk.