An inquest into the death of a man from Legionnaire's disease at the Royal United Hospital has been told of failures in the hospital's system for protecting patients from the disease
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Inquest into Legionella death told of failures by Royal United Hospital to keep water supply safe
An inquest into the death of a man from Legionnaire's disease at the Royal United Hospital has been told of failures in the hospital's system for protecting patients from the disease.
Bath man Terry Brooks, 68, died from the water-borne illness while he was an inpatient at a cancer ward at the hospital in July last year.
Subsequent testing by Public Health England found that the water supply in the William Budd ward was contaminated with Legionella, but that three homes that Mr Brooks visited during the period when he could have contracted the disease were free of the bacteria.
Brian Gubb, head of estates at the hospital, the department responsible for the hospital's water supply, told the jury on Monday (February 8) that one of the main ways to protect patients from Legionella was to control the water temperature.
Legionnaire's disease is caused by Legionella bacteria, which are usually found in low numbers in natural water sources but can multiply rapidly in man-made water systems that are not kept hot enough or cold enough.
After Mr Brooks's death, Mr Gubb's staff discovered that the temperature of the water in a return hot water pipe was between 35C and 40C – a temperature at which Legionella can thrive – instead of the 50C it should have been at minimum.
Further investigation discovered that there was a broken pump in a separate water loop feeding the isolation part of the William Budd ward, known as the annex, where particularly vulnerable patients such as Mr Brooks stayed.
The broken pump meant that the hot water was not being returned to the boiler regularly enough to stay hot enough.
The estates department did not have up-to-date diagrams of its water system, so was not aware that the annex was on a separate water loop, that the broken pump existed, or indeed, how long ago it had stopped working.
Water temperature checks taken each month at the kitchen sink at the other end of the ward did not reveal the problem.
Water samples taken from the same kitchen sink each month and tested for Legionella came back negative on July 6, but were positive along with 22 other samples taken in the ward on July 22, the day before Mr Brooks's death.
After the contamination and the broken pump were discovered, several measures were taken to protect patients, including replacing the broken pump and overheating the water supply to kill the Legionella bacteria.
But subsequent water samples tested positive for Legionella, as late as September 2015. Special filters on the ends of the taps to prevent Legionella from getting through were installed within a week of Mr Brooks's death.
Mr Brooks said there are problems with the system that pumps hot water around the William Budd ward that mean, although the water is hot enough when it leaves the boiler, it is not necessarily hot enough by the time it reaches the taps and showers.
He said £250,000 is being spent to upgrade the system that supplies water to the ward, and that, until that is completed, the special filters will stay on the ends of the taps and shower heads in the ward.
The PAL filters keep out any micro-organisms bigger than 0.2 microns and Legionella bacteria are 0.5 microns in size, he said.
The hospital has also introduced electronic temperature monitoring at every one of its water outlets, and is the only hospital in the UK to have done so, he said.
The Health and Safety Executive found breaches of health and safety law during an inspection of the hospital on August 27 and issued a "notice of contravention" and "improvement notice" the following day.
The improvement notice, from public health inspector Dr Susan Chivers, said the hospital was contravening the Health & Safety at Work etc. Act 1974 because: "you have failed to carry out a suitable and sufficient assessment of the risk of exposure to legionella bacteria from your hot and cold water systems because you have not completed an up-to-date survey of your site's water systems, including the schematic drawings, in areas of the hospital identified as `high risk`."
The inquest continues at Avon Coroner's Court.