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Legionella Control - Berkshire

A wash basin in a Reading Borough Council care home was the most likely source of Legionnaires’ disease that killed a 95-year-old man, an inquest heard.

Lewis Payne, of Knights Way, Emmer Green, was staying in The Willows care home, in Hexham Road, Whitley, when he contracted Legionnaires’ disease. 

Flaws in staff training, specific to Legionella Control and relating to record keeping and auditing at the home was also revealed at the inquest into his death. 

Mr Payne became a resident in one of the home’s intermediate care flats from September 24, last year.  Nearly three weeks into his stay he complained of feeling unwell. 

When his condition did not improve an out of hours GP was called – he diagnosed pneumonia and a urine infection. Mr Payne was given the option of staying at The Willows with a stronger dose of antibiotics or being taken to Royal Berkshire Hospital (RBH) but he asked to stay. 

On October 16 Mr Payne’s symptoms worsened and he was taken to the RBH where his urine tested positive for Legionnaires. 

Despite receiving treatment he died on November 1st.  An investigation was launched and Legionella Bacteria were found in the wash basin of Mr Payne’s flat, one of the upstairs showers and an outside tap. 

As Mr Payne had only had a basin wash while at the home the only likely way he came into contact with the bacteria was from the tap in his room, the inquest heard. 

The care home’s water system had been Risk Assessed. The risk assessment was then kept with a log book in the care home office and should have identified what the care home was responsible for in terms of managing the water system and what other parties were responsible for. 

However, The Willows unit manager admitted before Mr Payne’s death she was not aware of the council’s Legionnaires policy and had never had specific Legionnaires training. 

Although she was aware there was a log book she had very little to do with it as she had delegated health and safety management to her deputy, and the care home’s handy man physically carried out the checks.  It did appear however that not all maintenance tasks were being undertaken. 

Since Mr Payne’s death the council has introduced numerous measures to ensure the same mistakes are not repeated. 

Engineering services manager for RBC, said: “Mr Payne’s death cannot be left to go in vain, we must learn from that.” 

Since the incident the council has fitted every water outlet in the building with special bacteria filters. 

Recording a narrative verdict, Berkshire coroner Peter Bedford said: “Tests confirmed that the strand of Legionnaires found in the wash basin of Mr Payne’s room is the same type, that is not particularly common, found in his urine sample, supporting the view that on the balance of probability the tap was the source of the Legionnaires. 

“While Legionnaires was the principal cause of death subsequent attempts to eradicate it has not proved completely successful”. 

“Investigations have identified flaws, in particular in regard to training, staff record-keeping and audit-taking but it is not possible to see from the evidence that these flaws contributed directly to Mr Payne’s death.” 

In a statement issued after the inquest the council expressed its condolences to Mr Payne’s family and friends. 

It added: “As an added precaution, the council has also carried out a review of all of its buildings stock across the borough and a detailed programme is in place for the council’s Legionella officer to visit sites on a monthly basis to ensure all relevant procedures are being followed. 

“Reading Borough Council has taken the opportunity to re-emphasise to all relevant staff the importance of maintaining essential health and safety systems and to ensure that all records are kept up to date and are consistent and accurate. We are confident the measures put in place by the council will ensure this happens.” 

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