Good morning and welcome to the 21st meeting of the Health and Sport Committee in 2012. I remind all those present that mobile phones and BlackBerrys should be turned off as they can interfere with the sound system.
Thank you for inviting us.
Thank you very much. Fiona McLeod will ask the first question.
I have a number of questions for Pam Waldron of the HSE, but some of them may be applicable to Colin Sibbald, so it would be fine if he feels that he has answers to give.
Convener, I have been asked a lot of questions; I think that I have made a note of all of them. I may not have the exact detail with me to provide some of the information that has been asked for. Please forgive me while I find the relevant resources and information. [Interruption.]
Yes; I asked two related questions. You have told us what happened going back to 2008, but what about the past 10 years? I realise that you might have to send us that information.
Yes.
I also asked about your inspectors’ average length of service.
I could give you a guesstimate of the average length of experience, but it is probably more appropriate if I agree to send you that information instead. As for the number of inspections in Lothian, I do not have the exact breakdown with me but I can come back to the committee on that. Are you talking about the local authority area?
Yes, where it is contiguous with the NHS Lothian area. If you cannot give me that information, does that mean that you cannot tell me how many at-risk legionella sites have been inspected?
Given that legionella is a ubiquitous bacterium, there are probably quite a significant number of at-risk sites. After all, we are talking about not just cooling towers, but all hot and cold water systems. Again, I do not have an exact breakdown for those numbers. To give you an idea of scale, though, I point out that there are 4,600 notified cooling sites across Great Britain and if you add to those the number of hot and cold water systems, spa pools and so on in operation, it is clear that we are talking about a significant number. I also note that we do not record our legionella visits separately.
I understand that under the approved code of practice on Legionnaire’s disease it is the operator’s duty to “manage and monitor precautions”. However, the fact that the approved code of practice was being used—and by so many—should have been putting up risk flags for the HSE and should surely have given you an idea of the number of at-risk sites in the area.
The approved code of practice is widely used because, as I said, legionella is a risk in all of these sites. However, the sites vary from the complicated systems in cooling towers to hot and cold water systems in hospitals, care homes and the like, some of which are fairly straightforward and some of which, as in hospital water management systems, are more complex. Other sites might be involved in manufacturing. Legionella is fairly ubiquitous and we have put in place a readily available website with easily accessible guidance to allow people to decide where they sit on the risk spectrum.
I understand that, but the ACOP says that the operator has to “manage and monitor precautions”. Does the HSE have no oversight of how someone is managing or monitoring their own precautions?
We carry out inspections, but the responsibility for managing risk must lie with the duty holder. Legionella is a good example of why that should be. An inspection is only a snapshot in time; given how legionella proliferates, a problem might emerge weeks after that inspection has taken place. What we are interested in is how a company consistently manages its risk.
If an inspection is only a snapshot in time, where does the HSE’s preventative agenda come in? What flags up to you or makes you decide that you need to carry out that one-point-in-time inspection? Is an inspection a preventative measure or is it, as in the current situation, entirely reactive?
Sometimes inspections are reactive and take place after an incident or a complaint. We do have a proactive agenda and carry out proactive inspections in high-risk sectors, but not necessarily those with legionella. After all, that is only one of a number of risks that companies have to manage.
What about the three improvement notices that were issued when the sites were last inspected?
I am sorry—what was the question about the notices?
When were those sites last inspected prior to the current improvement notices being issued?
On the inspection history, the issuing of improvement notices is a matter of public record. I want to make it clear that that is not by any means an indication that these companies are the source of the outbreak.
When you referred to the 4 February 2010 visit to Macfarlan Smith, you said that that was to look at its management of legionella.
Yes.
Given my previous questions, what made you decide to carry out that visit?
It was part of a broader programme of legionella visits that we were carrying out across Great Britain.
Can you send us details about that programme—why it arose and why it was a specific programme? I am trying to establish the following, but I do not seem able to—when do you proactively monitor a site that has a high risk of legionella to ensure that the ACOP is being adhered to?
Programmes will not be specifically for legionella. The company is managing a number of significant risks as well as legionella. Legionella is a cross-sector issue. We concentrate at the moment on high-risk sectors, which those companies are not part of. From time to time, we carry out programmes of preventative inspections that look at particular topics. That was what was behind the specific legionella visit to Macfarlan Smith in 2010.
What made you decide that legionella was a topic worth exploring in 2010? You said that you look only at high-risk sectors—why did you decide that legionella was a topic?
I do not want you to think that at that point in time we suddenly discovered that legionella was a high-risk topic. We do a number of things as a responsible regulator. Proactive inspection is just one small part of that. We issue guidance. We work with stakeholders and with other people in the industry such as the water cleaning companies and the cleaning contractors. We do a wide array of things—proactive inspections are a small part of that array.
That is fine. Does Mr Sibbald have anything to say on that topic? I am not going to ask any more questions.
Staying on the inspection regime theme that Fiona McLeod has kicked off, can the other witnesses give any useful evidence on the inspection regime other than the shared responsibility of the local authority in certain premises—is there a difference? Who has the responsibility for the inspection and monitoring of food and drink?
I have that responsibility.
If the committee came to the view that more resources may be required in this area, you would not want any more.
I can always use more resources.
Thank you.
We concentrate on densely populated areas because that is where the biggest risk is. We probably chose the area to which you referred because it linked with other aspects of our inspection programme at that time. We would certainly focus on things such as cooling towers, which are one of a number of pieces of equipment that are responsible for legionnaire’s disease outbreaks.
Has there been an outbreak of legionnaire’s disease in that area in the past?
Yes, there has.
Was that on one of the 16 sites that have been identified?
Six sites.
We are going by press reports. I thought that there were about 16 sites that could have contributed—
There are approximately 16 sites on the cooling towers and evaporative condensers register that is held by the City of Edinburgh Council.
Yes, and one of those, in the area in question, was identified in the past as a source of legionella.
No, that is not correct.
It was not connected at all. There was no outbreak in that area in the past.
One of the sites was investigated but was discounted.
When was that?
My recollection is that it was 1994.
I just wondered whether the logic was that you planned work in that area because there were previous outbreaks. Is that not the case?
I am sure that there was some logic, but I do not think that what you suggest would have been part of the equation.
Okay. Fiona McLeod focused on the inspection regime for the sites in question and how many inspections there were. Have all the sites that could be linked to the present outbreak been inspected at this point?
Indeed. We have been discussing this morning that there are in excess of 60 sites in the outbreak area.
Sixty sites.
They have been visited by us and by City of Edinburgh Council officers.
Realistically, what kind of site visit or inspection can that be other than just contacting the management?
We have been working with occupational hygienists in teams to carry out some visual inspections as well as assessing records and looking at sampling records.
Have all the records on those sites been inspected to ensure that the operators conform to a pretty rigorous risk management regime?
Some sites were visited to exclude them as potential aerosoling sources. Where there was no discernible risk, there would have been no requirement to examine any records. Some of the sites—a bowling green and sites like that—were visited to ensure that they did not store water in such a way that it might have been seeded by a source, wherever it was, and subsequently aerosolised. That was proactive, preventative work for the future, as opposed to work that dealt with the outbreak that we are discussing.
But sustainable prevention work in the future will have the managerial capacity to manage that risk and hazard, will it not? It will ensure that people take responsibility, keep up the records and comply with Health and Safety Executive guidance.
Yes, but the vast majority of the 60 sites that were visited pose no legionella risk of any sort whatever.
So if those sites are not maintained in compliance with the inspection and risk management regime that the Health and Safety Executive lays down, that does not matter.
Many of the places that were visited are not covered by the approved code of practice—L8. As I said, they were visited to ensure that they had not become compromised as a result of any droplet spread from an as-yet-unidentified point source.
It is interesting that those sites could be identified in relation to the outbreak but not required to comply with the Health and Safety Executive’s rigorous standards for controlling legionella.
The 60 sites were risk assessed by competent people and the decision was made that no risk pertained to the vast majority of them and that the usage and storage of water at them would not have been compromised by any plume.
Is Ms Waldron content with that?
The approved code of practice applies to higher-risk systems, but the Health and Safety at Work etc Act 1974 applies to any work activity. As Colin Sibbald said, risk assessments would be required.
I ask Dr McCallum and the other witnesses to tell the committee in detail about the approach that NHS Lothian and the incident management team have taken to addressing what is clearly a major public health challenge. What approach was taken in identifying the outbreak? What steps were taken to diagnose cases of legionnaire’s disease? What measures have been taken to limit the outbreak’s impact on the general population, on at-risk and vulnerable groups in the older population and on people with underlying health conditions?
Thank you for those questions, which I will pass to Dr Duncan McCormick, who chaired the incident management team.
I can give a little history to the outbreak’s development, which might help members to work out how such things progress.
I think that that covers the identification point.
Was your other question on diagnosis?
It is on diagnosis, and on how to limit the outbreak’s impact on the wider population.
Diagnosis is quite complex. There are three main ways of diagnosing and confirming legionnaire’s disease. One involves a urine test, which shows the antigen of the legionella bacteria, which is a particle of the bacteria in the urine. That can get a result relatively quickly. The second method involves a blood test, which shows the antibodies to the bacteria. It is not such a rapid test; it takes a bit longer, and we have not used it very much in diagnosis in this outbreak. The third method involves the patient coughing up a sputum specimen, which is tested for particles of bacteria.
That is very helpful.
On how we have sought to limit the impact on the general population, the first thing we did was very quickly make a hypothesis based on mapping, which is the standard technique for any outbreak—especially of legionella. I hope that, by taking that rapid action, we have managed to reduce emission of bacteria from the potential sources.
On your last point about healthcare practitioners—GPs in particular—how do we ensure that doctors who do not have first-hand experience of legionnaire’s disease are fully informed about how to diagnose and treat it? What steps are being taken to increase awareness of how to manage the disease’s effects?
The initial letter that went out was, because of the circumstances, a short letter that described the symptoms and signs, recommended the antibiotic to use—because we had a microbiologist involved—and recommended the test to use. Those are the three key things that a GP needs to know. It went out on the Sunday night, and was updated almost daily over the next week.
I should say for those who are not aware of the procedure that the letter went out not by post, but by secure fax, which is the usual emergency cascade procedure. On the Monday morning, all the general practices in the area were telephoned to let them know what was going on and what the symptoms are and to tell them to expect patients. That was followed up later in the week with a further phone call to ask how things were going and to reinforce the messages.
I thank Dr McCormick for his detailed evidence.
To add to that, although the problem was identified in Edinburgh, one key measure that was taken on Monday 4 June was to inform all the other national health service boards in Scotland that an issue was under investigation and to ask for early reporting of any such cases in other board areas, because people travel. As information became available about the emerging issues, we in turn shared with the other boards information in the letter format that Duncan McCormick described, so that they were made aware of the practical clinical management issues. We also sent information to our colleagues in the rest of the UK, particularly in the Health Protection Agency, through an early alerting system that is in use across the European Union. In turn, we asked them to relay that information through our colleagues in the European Centre for Disease Prevention and Control.
Based on the evidence that we have heard, the response certainly seems to have been robust and comprehensive. However, are there any lessons that should be learned from the experience? In particular, are the current systems fit for purpose? On the basis that we should always strive for improvement, are any changes to public health procedures required?
The process following the investigation of an outbreak involves a formal incident management team report and a formal debriefing process that picks up the operational lessons to be learned. There is then a more formal process, which the emergency services call a cold debrief and which identifies what we have learned from the incident about quality improvements, changes to education and training and different ways of doing things. We then feed that into the national health protection networks and back to the Scottish Government, as we would for any other emergency. I am sure that, with hindsight, we would do some things differently, but I would like to wait until we have a systematic overview of those so that they can be thought through and prioritised.
That is helpful. No doubt, you will share that with the committee in due course.
Indeed.
On the lessons, one issue that was mentioned earlier and which is in Dr McCormick’s report is the role for GPs in such incidents. I do not know whether the fact that legionnaire’s is not a notifiable disease is an issue in relation to GPs’ role. It was not until someone had the disease and presented at hospital that we became aware and all the other issues kicked in. Is the urine test something that a GP could have done?
We have investigated a large number of potential cases of legionellosis, which is legionnaire’s disease and the milder forms, during the past three years, but we have had fewer than five confirmed cases in each of those years. It is a reportable disease so, if a test is positive, we are required under the Public Health etc (Scotland) Act 2008 to know within a couple of days.
The disease is not reportable by GPs.
It is a laboratory notifiable disease.
That is why I mentioned GPs.
When they see the patient, a general practitioner or any other medical practitioner would not necessarily know that the person has legionnaire’s disease. They might know that the patient has a severe pneumonic illness and that something has caused that pneumonia, but they would not necessarily know that cause. That is why we need laboratory information about the cause, and pneumonia is often how we seen the disease presenting. That is why there is a distinction for laboratory reportable infections, which are notified to us by each of the laboratories and each of the reference laboratories across the country. That information is collated in each of the health boards and centrally in Health Protection Scotland.
The convener has anticipated my area of questioning. If a general practitioner saw the symptoms that were described in the letter, and they did not do a test but went ahead and treated the patient, there would have been no notification of the fact that the patient might have had legionnaire’s or Pontiac fever at the lower level, so the question about the disease being notifiable is difficult. I understand that confirmation is required, but should all GPs who saw a case and used the appropriate antibiotic on the supposition that it might have been legionnaire’s have done a rapid urinary antigen test? Otherwise, we really do not know the true extent of the condition, and the system does not ensure that we would know the true extent during an outbreak.
Initially, we recommended that GPs do a urinary antigen test on milder cases with symptoms as well as on the severe cases. It should be borne in mind that people turn up every day with symptoms that could easily be legionella or something else, and GPs are very good at sifting out which need further treatment and which do not. However, during the week, it became clear that testing every single person who turned up would be to the detriment of making sure that we tested sick patients who needed very quick diagnosis. Towards the end of the first week, it was decided that we would recommend to GPs that they manage the patients clinically, and that they code patients by one of the three or four legionella Read codes. That was not disseminated to GPs, but it is normally what happens in such situations.
I understand that you do not want your laboratory to be totally overwhelmed with suspected cases and that sifting out mild forms of legionella from other conditions is very difficult, but should there be a system that ensures the collection of urine, even if that urine will not be used immediately? In other words, a urine test should be required to be taken if the person’s symptoms are mild and the GP thinks that they might have legionella and is therefore going to code them. The urine may be stored for future use or, if the condition got worse, it could be tested. That would allow us to see the extent of the mild form.
We have around 1,500 urine tests stored, which is quite a good, rigorous sample.
I hope that you have the resources to be able to deal with that.
We hope to get there. We hope to follow up with serology testing, as the urine tests were negative. We have around 1,500 negative tests, and we want to do follow-up serology tests with the blood tests to find out whether there is evidence of infection that was not apparent in the urine test. Such evidence will perhaps be apparent in a week or two through a blood test. We should have the information that you seek through that.
That is very helpful and answers my question.
We have done that with four of the six sites, which were originally checked out on the Sunday and the Monday. We asked people to look at the potential that standing water on their sites had become contaminated from a plume on any of the sites, in order to exclude that possibility for re-seeding of the towers that were subsequently cleaned. We have had information from the duty holders at those locations that they have examined that possibility and excluded it.
We have also looked at whether those premises were the source. We have not looked at only what we have thought might be the epicentre and outward spread. To pick up Richard Simpson’s point on whether we looked at the areas around that to see whether the source lay outside it, that was done on our visits to some 60 places, among which there was great variety.
That is fine.
Can you explain further the process to get from 60 to six places? There were visits, but how did you manage that among you? How do you eliminate a site?
No; we got from six sites to 60.
So, you worked up the way.
We looked at the premises that were on the register of cooling towers and evaporative condensers and were within the theoretical distance of a plume’s spread. We dealt with two premises on the Sunday, two on the Monday, and two on the Wednesday. I stress that the two on the Wednesday were theoretical—they were based on modelling. For topographical reasons, we did not believe that either could be the source. Because there were no environs-related cases between the cooling towers at the last two locations and Stenhouse, that was done on a purely precautionary basis.
This is maybe a daft cousin question. You mentioned stagnant water. Do ambient weather conditions have any impact?
You are asking whether ambient weather conditions have any impact on the temperature of stored water. If the stored water is at less than 20°C, there should be no risk of legionella, even if it is aerosolised.
The problem assessment group was called on the Saturday. Am I correct in saying that if there are two cases, you get a problem assessment group together, before you create an IMT?
On the Saturday, there was no formal problem assessment group, but the problem was assessed by the key players—microbiology, public health people and Health Protection Scotland. On the Sunday, we started off the problem assessment group, which 10 minutes later turned into an IMT.
The other issue is the cascade. I understand that the local electronic cascade to general practitioners seems to have been quite effective, but we know that there were considerable public gatherings in the area. I believe that there was a march in celebration of some football thing—I am not sure what that was about. We now know that there are cases elsewhere in Scotland.
That is right. A similar arrangement is in place within each board area so that, following receipt of information from Health Protection Scotland, the boards cascade the information down to medical practitioners locally. Over the course of the initial weekend and subsequently we kept NHS 24 informed because it, too, provides a national service. That is a key organisation that all of us were keen to keep updated.
Is the outbreak finished? My understanding is that the incubation period is 10 to 14 days. The toxic shocks were administered to the six cooling towers by Wednesday. Are we still getting cases? If we have treated the towers, and they were the potential source, should the outbreak be over?
The IMT will meet later today and will decide the date for declaring that the outbreak is over. The incubation period can be up to 19 days. We also have to look at the date from which we have seen that the towers have been definitively treated. That will be discussed later.
Jim Eadie asked about lessons to be learned. When I heard which people are most vulnerable to legionella, I was very worried because it sums up a lot of the people who live in the area, in terms of income, health, demographics, density and access to things like broadband.
Those comments are helpful and the issues will certainly be covered in any analysis. The member will know that on the Sunday night, as soon as we were aware of what was happening, we briefed the media to ensure that they all received reliable information. We had already briefed accident and emergency, unscheduled primary care services, general practitioners and hospital staff. Over the next couple of days, we set up a helpline through NHS 24; in doing that, we found the use of staff from programmes such as keep well to be very effective in engaging with patients with additional communication needs, who have limited literacy or are very vulnerable. We also ensured that information was available on Facebook, Twitter and the internet, and we leafleted the areas in question.
We informed nursing homes of the situation both on Sunday night and subsequently; indeed, they were involved in all the secure faxes. We also discussed with the primary care office the possibility of sending out district nurses, who deal with more vulnerable people in communities, to identify people quickly and were told that some of the people whom you highlight are already covered by district nurses’ case load and are supervised routinely; indeed, district nurses were undertaking that supervision, particularly in light of the legionella outbreak.
It was a brilliant weekend and it was a holiday weekend. Given that people in that area live in quite small flats, loads of people were not in or had their windows open. Another thing that occurred to me is the fact that the area is heavily tenemented. Anyone who has done any leafleting in the area will know that it is hard to get into those properties. You might think that you have leafleted the area when, in fact, there are piles of leaflets at the bottom of stairwells.
Those are good points. Yesterday, we got a report on leafleting and your point about getting into tenements is valid. Normally, leafleting is done in the early morning, so that someone will be in and the person who is delivering the leaflets will be able to press the buzzer and get in. Because of the desire for rapid turnaround in this case, some of the leafleting was done in the afternoon, which means that some tenements would not have received their leaflets. Instead, leaflets were left in high footfall areas such as supermarkets, so that even if people did not have a leaflet delivered, they would get one if they went out to a local shop. However, it is clear that such an approach will not reach everyone.
I would like to follow that up with a brief additional question. How was the outreach in minority languages? I am thinking of eastern European languages, in particular, because the eastern European sector is very strong in Gorgie.
That is a good point, too. The leaflets were only in English. It would have been useful if we could have issued them in different languages, especially Polish. That is definitely a lesson to learn for next time.
I completely agree with everything that Sarah Boyack said on how the situation was dealt with, but the point that I really want to look at relates more to the issues that Fiona McLeod raised regarding inspection. Figures of six, 16 and 60 have been mentioned. As I understand it, the HSE served three improvement notices. Is it correct that only three notices were served in relation to the legionnaire’s outbreak?
It is correct that three improvement notices were served as part of the investigation.
How many of the places that were investigated could have been served with an improvement notice, based on the investigation and the nature of the equipment? Is the figure six, 60 or something else?
Enforcement action was taken in line with our normal enforcement policy. The action that was taken was the correct enforcement action. The correct number of notices was issued.
What I want to know is how many premises were given a clean bill of health that could have been served with an improvement notice because of the equipment? In other words, what was the incidence of an improvement notice being required among the sites that could have been served with such a notice?
If a notice was required, a notice was served. I think that you are asking whether there were shortfalls that we did not address with a notice.
No, that is not what I am asking. Different kinds of inspection have been mentioned. I presume that the 60 sites where there was a possibility of infection by the plume and secondary infection are distinct from potential sources. Am I right in thinking that there were six potential sources? Six towers—or was it 16?—were assessed as potential sources for an airborne infection.
We looked very broadly at potential sources, not just at those six. That was the whole point: one looks immediately at the most obvious sources. That was what Colin Sibbald was referring to; he might want to pick that up.
Of the six premises that are on the City of Edinburgh Council’s cooling towers and evaporative condensers register, improvement notices were served—sorry, I will begin again.
It was actually three notices, as I said earlier: two at one company and one at another. Those notices, plus the notice that Colin Sibbald mentioned, add up to four.
So there was one notice from the council and three from elsewhere. That means that the failure rate was 67 per cent, and it was 50 per cent for the HSE inspections if three improvement notices were served as a result of six inspections. Is that correct?
I am sorry—I must be missing the point. Are you saying that there is a high rate of enforcement in those six premises? Is that your question?
I am wondering whether we should be concerned that six places were inspected and three failed.
Three were given improvement notices—
Sorry—three were given improvement notices.
That shows a contravention, which showed that the standards fell below those that are required by the approved code of practice.
I will take that as a yes. Do you think that that is the rate more widely around Scotland?
That is something that we may look at. There is concern that compliance with the approved code of practice appears to be creating some problems, not just in Scotland but more broadly. We are reviewing our approved codes of practice at present, but more importantly we have commissioned research by the health and safety laboratory on the past 10 years of outbreaks so that we can see what lessons need to be learned.
One of my constituents who had received a diagnosis of legionnaire’s disease contacted me to ask whether suspect facilities or facilities that could cause a legionnaire’s outbreak were inspected by relevant external authorities on a daily, weekly or monthly basis. I take it from the earlier mention of 4 February 2010 that there is an external inspection every few years.
There are no set periods for inspection. As I said, we look at high-risk factors and the way in which the duty holder is managing health and safety. We select a number of risks, which may include legionella or other risks within the business, and look at how well they are managing those.
You said that the February 2010 inspection was part of a wide programme of looking at legionella management. Was it possible for sites that were visited as part of that process to receive improvement notices on the basis of the inspection in the same way as the sites that were visited following the current outbreak?
I will keep it in general terms, if you do not mind, but what you suggest was indeed possible.
How big was the programme? Was it across the UK?
It was.
How many sites were visited?
Some 120 sites.
How many improvement notices arose from that?
I cannot give you an exact figure just now, but I could give it to you in writing later.
I would be interested to receive that.
Convener, I have the inspection figures that Ms McLeod asked for earlier, if you want them now.
Yes, thanks.
Ms McLeod asked how many proactive inspections took place. I did not think that I had the Edinburgh figures with me, but I do. To give the committee an idea of the scale of the work, the HSE is responsible for inspecting about 900,000 premises. In 2011-12, HSE inspectors undertook 21,603 proactive inspections.
Was that for the UK, Scotland or the Lothians?
It was across Great Britain. You asked earlier for the figures for the city of Edinburgh; in 2011-12, we undertook 361 inspections of sites within the City of Edinburgh Council or EH postcode area.
Those were all kinds of inspections.
Yes. As I said, in an inspection we assess how a company manages health and safety rather than focus on a specific issue. The important thing is how the company manages health and safety. Within that, we hope to ensure that the company identifies the significant risks, understands what they are and either eliminates or controls them—that is the purpose of an inspection.
Are both agencies confident that the majority of companies that have the cooling systems for which you would rather see an alternative are fully appreciative of their responsibilities, given the inspection regime that is in place?
The companies with those systems understand what their responsibilities are and engage contractors to assist them in managing what can often be quite a complex challenge.
I was involved in the investigation of the outbreak in the early 90s in south-west Edinburgh, so I am acutely aware of the reduction in the number of wet cooling towers and evaporative condensers in the city as a whole. I estimate that there are less than half the number that existed then.
So, it is a trend. How difficult is it to replace those towers? I know that if you cannot isolate a tower, so to speak, you can replace it or get an alternative. However, if 50 per cent of the cooling towers in the city have disappeared, how do we encourage other companies to follow that example? Is replacing the towers a costly exercise? Do some companies keep them because there are processes that they cannot do without?
Some processes might require the towers to be retained for technical reasons, particularly if they are part of industrial cooling systems, on which I do not profess to be an expert. Most of the systems that we have historically enforced and currently enforce are air conditioning systems. I believe that there are very acceptable alternatives to using wet systems for air conditioning in office blocks.
I am keen to follow up on the issue of the HSE’s system of inspections. With regard to risk assessment, how many of the 361 places in the Edinburgh postcode area that were visited in 2011-12 for a variety of reasons had cooling towers or other risk factors associated with potential legionella outbreaks?
There will have been some but, because I do not have all the details about those 361 visits, I cannot specifically say how many. Nevertheless, I point out that we would have been working in high-risk sectors and dealing with, for example, manufacturing premises; moreover, some of those visits would have been part of an investigation rather than an inspection. Legionella is one of a number of things that are deemed to be a potential major concern in any inspection and, if there were a legionella risk, the inspector would cover that in discussions about the overall management of health and safety.
That is precisely what I wanted to clarify. Are you saying that irrespective of the main reason for the HSE’s visit, and even though you might have been making a visit for an completely different reason, the 361 premises that were visited in 2011-12 would have been screened as a matter of course for risk of legionella and, if such a risk emerged, they would then have been inspected? Would that flag up on your system and lead you to decide that, as the HSE has mainstreamed its duty with regard to legionella, you should inspect for it while you are on the premises?
Such a risk would be flagged up not on our system, but to our inspectors, who are trained to understand the risks of legionella and would, if there were a legionella risk in a business, cover the issue as a matter of course. The answer to your question, therefore, is yes.
I think that I am getting the answer that I want, so I do not want to push the issue any further. However, I believe that across the UK about 21,000 inspections have been made.
Yes. There were 21,603 inspections in 2011-12.
So, irrespective of why the HSE was visiting those premises, if any of them had cooling towers or anything else associated with legionella risks your inspectors would test for that as a matter of course?
They would be inspected, not tested. Even in some of the places that we might visit if we found that they had hot and cold water systems, the operator would be assessed on whether they understood the legionella risk and how well they were managing it. We do not perform tests—we do not take samples, for example—but we assess their compliance against the benchmarked standard in the approved code of practice.
I am sorry for my slip in terminology, but would there be any benefit in inspectors carrying out spot tests during a visit?
No. As I have said, the nature of legionella means that sampling is notoriously unreliable. The more important matter is whether a system for dealing with it is in place. I guess that the key baseline is whether operators understand that they have a legionella risk and the issue, then, is what they are doing about it and whether they have systems for controlling it. A sample taken at one point in time would not give us an accurate picture of how well they were managing the risk.
That is helpful.
I have a final question. When Jim Eadie asked about the lessons to be learned, Dr McCallum replied by outlining a debriefing and reviewing process. Given that the answers to Marco Biagi’s question suggested that in 80 per cent of the six premises that were giving concern the duty holders failed to follow ACOP L8, I wonder whether the HSE and the health officers can tell us how they will debrief and review the situation and apply what they learn to their own practices.
Although each agency has its own statutory responsibilities, the initial process is a multi-agency one to ensure that we do not lose lessons that should be shared across sectors.
We would always hope to learn lessons from any outbreak like this. We will be discussing it on Thursday at the HSE’s legionella committee. We will have discussions with our colleagues at the City of Edinburgh Council but it is too early to say what might result from those discussions. If we feel that there is any need for an adjustment to our current programme or the plans that we have for dealing with legionella, we will clearly take those points on board.
The system is one of assessing high-risk areas and inspecting as required. According to the memorandum, it is a system of self-regulation. Are the sample results always notified to HSE, whether they are positive or negative?
No, they are not. There is no requirement to notify sample results to us or the local authority if the premises are local authority-enforced premises.
Right. How do you get a feel for whether the sampling is being done properly at the frequency that you recommend? You have no real way of knowing that.
If you were to ask me whether I know at any point in time how many people are doing that in the city of Edinburgh, I would have to say that I do not. However, we know that there are robust systems in place that use competent persons. We have seen no indication that people do not have systems in place.
Presumably, a positive sample can come through at any point before the water treatment is done. A positive sample is not notified to anyone.
No.
We are talking about source samples, not clinical samples, and source samples are not notified. If source samples were coming up positive more frequently—if there were rising levels of positive samples—even if they were being treated, would that not indicate that problems might occur?
There are different protocols for different types of sampling with different time intervals. The results that were most important to us early in the current investigation related to total viable counts in the towers and to the presence of free disinfectant in the towers. As a matter of routine, we would review the sampling protocols of premises that we were inspecting that had cooling towers or evaporative condensers to see whether the company was applying the approved code of practice, as far as we were able to determine. At the moment, the City of Edinburgh Council has no plans to stop carrying out periodic inspections of the premises for which we are responsible that have cooling towers.
But we have no electronic data transmission system of the measures that individual companies are adopting, so you have no way to check, except when you inspect.
We inspect duty holders’ records, training records, records that relate to chemistry and microbiology from the towers, and who the company is employing and whether they are of the calibre that one would expect. All those things are looked into.
How frequently do you do that?
It depends on the risk assessment at the previous inspection. We currently have a three-year inspection programme. The other premises that we have discovered is now ours to enforce will shortly have a baseline inspection, and the next full inspection will be programmed at that time.
So it is a three-year inspection programme.
It might not be. It depends on the risks that are identified at the time of the inspection.
A company in Linlithgow contacted some of us about a rapid test that could be applied to water treatment works. There was some discussion about its application being refused, although it might have helped. Would anyone like to comment on that?
Any test that might be of use in any investigation will be discussed as a matter of course at any incident management team meeting.
I hope that that system will be looked at, because I understand that it has been approved by the Dutch Government’s equivalent of HPS—at least, that is the information that I have been given.
As of 25 June—yesterday—at 12 o’clock, we have 48 confirmed cases and 47 suspected cases, which is a total of 95.
The potential number is 95 cases, if all the suspected cases are confirmed. What clinical follow-up do you intend to put in place? People who have had relatively mild symptoms might have longer-term problems.
The clinical follow-up will be as it is for any severe disease or illness that the NHS has dealt with. GPs will collaborate with hospital doctors to ensure that people receive continuing care, as they need it. There have been other people in intensive therapy units and on the wards during the outbreak, of course, and all people get the same standard of care.
I take it that there are no complications that require a particular specialist, and that if a person has cardiovascular complications, for example, they will be seen by a cardiovascular specialist. Although there is no need for a special measure to be set up to follow up the 95 cases, I presume that someone will follow them, just to get information on the longer-term effects of the outbreak.
Patients will be followed up individually, as normally happens.
We plan to try to determine whether there are long-term consequences. Given the nature of the illness and the range of severity, and because a number of treatments were used, following a particular protocol, which appears to have been quite effective for many people but will not have been without consequence, there will be work to follow up those patients as a population. That is not to say that the individuals will not receive the high-quality clinical care that people with chronic respiratory illness in Edinburgh and Lothian would normally expect to receive.
On the duty of care, if a company tests its water and finds it to be contaminated, is it required to log that, just as it is required to log accidents in the workplace, to protect employees?
Records of that nature must be kept for at least five years, and corrective action that is taken must be recorded.
So that would be logged.
We would expect to see evidence of what was done to bring the tower back in line with L8, at any time when we inspected. That is the way that it is supposed to work.
Does that apply even outwith the context of an incident such as we are considering? Are you saying that if there is an incident in any working week, the company records it and the record is kept for a given time?
The duty holder must bring the system back into control and be able to demonstrate what they did and why. That must be recorded.
A lot of such work is done by contractors. How are contractors managed? Is there an inspection regime for them? Do they have to notify you that they have come across an issue?
A duty holder who employs a contractor must have a person in a senior position who understands what the contractor is doing and is able to deal with the contractor and ensure that they are meeting the requirements of the approved code of practice.
Have you had no dealings with the contractors who have been providing a service on the sites that seem to be connected with the incident?
We have had dealings with contractors directly at one site and, in the fullness of time, we will meet the duty holder and the contractor to define clearly the relationships and responsibilities. We do not have concerns about that site at the moment; our activities are aimed at implementing the decisions of the incident management team as speedily as possible.
Did I hear that you have some concerns about one contractor that is linked to one site?
The city council has no concerns over any contractor about the site at which it is responsible for enforcement.
The Health and Safety Executive may have some concerns about the contractor. We could be working together here, but it seems that some of the answers—
Sir, we are exactly the same as the City of Edinburgh Council. Whenever we look at compliance with the code of practice, we look at all the players. When we look at the company, which is the main duty holder in law, we will also look at the competence, selection and actions of the contractors—the process is exactly the same. We are having discussions with contractors in relation to this investigation, as you would expect us to look at the actions of all parties.
Does the Health and Safety Executive have any concerns about the contractors that have been involved with any of the six, 16 or 60 companies?
It would not be appropriate for us to comment further on that. We have had discussions with water treatment companies over a number of years, as it is important that they understand our standards.
I hear what you are saying. I will not press you, given what I said at the start of the meeting. That is fine.
We have heard from Dr McMenamin some of the timeline around how you have taken things forward at the level of the incident management team. Can you tell us whether it was Health Protection Scotland’s decision to request the Scottish Government to mobilise its resilience committee? What was the linkage between the health board on the ground, other partners and the role of the Scottish Government in co-ordinating the response? The incident was related to only one health board, but you seemed to say that you were able to disseminate the information to other health boards and outwith NHS Scotland. Did you do that yourselves, or did the Scottish Government do that for you?
As a matter of routine for any incident, as part of the on-call system, we alert the on-call consultant in public health in the chief medical officer’s team at the earliest possible opportunity. Therefore, they were aware at the earliest stage.
To return to Mr Smith’s specific question, HPS made no formal request of the Scottish Government to convene its resilience group. One of our many roles in such an incident and in the co-ordination of activity in a public health investigation is to offer advice and support. As Dr McCallum outlined, there might well be any number of local actions being taken, but there is a sharing of resource between NHS boards and my host organisation, Health Protection Scotland, so that, as required, we bring in team members from outwith an NHS board setting to help with the investigation of the incident or to provide support to ensure that we deal with the issues as rapidly as possible.
That sounds reasonable. The only question that arises is about how we gather the learning points for a future outbreak. It seems a bit unusual that the Government resilience committee was involved at that stage, although Dr McCallum correctly suggested some things that it might have been able to do had it been needed later, so there was a preparatory element to that approach, which seems reasonable. However, the more people who are involved in an on-going situation, the more chance there is that communication will become an issue. You are carrying out a review of your operations, but is the Government conducting a review, too? Have you been asked to give feedback to the Government on what worked well and what processes should perhaps be set up? Should there be a formal trigger for such a process in a future outbreak, or are we not sure about that yet?
The incident management team review will have at the table as part of the group one of the senior medical officers who is an experienced consultant in public health medicine. Under the guidance, there is a formal process for ensuring that the review’s final report is presented and shared.
To be crystal clear, that senior medical representative is from the chief medical officer’s team in the Scottish Government.
When will that report be available?
The guidance says that it should be available three months from the outbreak having been declared over. We will ensure that it is made available within the timescale that is required by the guidance.
It is slightly less than satisfactory that we cannot examine some of the themes and issues that the review will discuss. I will not press you now, but the committee might want you back when the report is finalised to get something on the public record about the conclusions.
I have a few brief questions. I see from the press statement from the Health and Safety Executive that the improvement notices are subject to a 21-day appeal period. Can the HSE say whether any such appeals have been lodged, or is that one of the issues that you cannot talk about?
It is probably not appropriate to talk about that at this stage.
Given that the system that was described earlier is in essence self-regulating—with the HSE acting as capacity builders—it needs the potential for strong penalties or sanctions if it is to work. I ask you to say—without talking about the current case—what penalties a negligent company, individual or other body could face if found to have caused a legionella outbreak.
Information is available on our website about cases that have been taken across the country for failures to manage legionella. In general, there is the potential to impose unlimited fines in such cases.
Having today’s discussion in public has been excellent. As a non-member of the committee, I am grateful to have been part of it.
An interim report will go to NHS Lothian’s board tomorrow; it has already gone to the City of Edinburgh Council’s policy and strategy committee. The board and the committee include elected representatives. The board has two appointed patient and public representatives and we have a network of patient and public involvement committees.
Will you ensure that the committee gets a copy of the interim report when that is appropriate?
Yes.
What is the Health and Safety Executive’s process? Will that go public, too?
The Crown Office and Procurator Fiscal Service is investigating the two deaths and the Health and Safety Executive is assisting that investigation. That is now a matter for criminal procedure.
Will your legionella review be a public document? Can that be made available to the committee?
The information is not public at the moment, but I am sure that I could provide an update on the outcome of the legionella committee’s deliberations and on any proposals that we might have, if that would be of interest.
That would be of interest.
Thank you for having us.
As previously agreed, the committee will now move into private session.
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