"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’ pneumonia.
Flaws in specific Legionnaires’ training for staff, record keeping and auditing at the home was also revealed at the inquest into his death yesterday.
Mr Payne became a resident in one of the home’s intermediate care flats from September 24, last year, for respite after fracturing his right leg.
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 1. Following the discovery of Legionnaires an investigation was launched.
Bacteria was 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 was overseen by the council’s Property Services – they contracted water expert SMS Environmental to carry out health and safety risk assessments that would identify any potential hazards. That 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 SMS Environmental was responsible for.
However, The Willows unit manager Christine Mabbott 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 James Skelt, and the care home’s handy man Matthew Smith physically carried out the checks. In a statement read at the inquest Mr Smith said he had not checked the outside taps or de-scaled the shower heads as he was not aware he was meant to do this.
It was also revealed when Mr Smith went away on holiday nobody carried out the checks in his place which is why there were holes in the records.
Since Mr Payne’s death the council has introduced numerous measures to ensure the same mistakes were not repeated.
Mark Attree, 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.
However, the level of Legionnaires bacteria in the water is increasing, suggesting the source wasn’t localised, Mr Attree said.
Barrister Bryan McGuire, representing RBC, asked Mr Attree if the paperwork had been better would Mr Payne’s death have been avoided.
Mr Attree said: “I don’t think so because of what has happened since, something that is in that water system is creating the bacteria and we can’t isolate where the problem is.”
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.”
Council confident measures are in place
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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