Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0046, written 9 Feb 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Feb 2015 |
|---|---|
| Reference | 2015-0046 |
| Deceased | Margaret Clarke |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Nicola Jane Mundy
Senior Coroner for South Yorkshire (East District)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1
CORONER
I am Nicola Jane Mundy, Senior Coroner for South Yorkshire (East District)
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On Monday 5th January 2015 I commenced an investigation into the death of Margaret Elsie
Clarke, age 77. The investigation concluded at the end of the inquest on Friday 9th January
2015. The conclusion of the inquest was 1a. Myocardial Infarction 1b. Legionella Pneumonia. It
was the unanimous conclusion of the Jury that on the 14th March 2013 Mrs Margaret Elsie
Clarke, date of birth 19.10.1935 attended Elements Spa, Rotherham, where she contracted
Legionella Pneumophillia, this led to her being admitted to Doncaster Royal Infirmary where she
died on 27th March 2013.
4
CIRCUMSTANCES OF THE DEATH
Mrs Margaret Elsie Clarke and her husband visited the Elements Spa in Rotherham on the 14th
March 2013 where they used a number of their facilities including a rain shower. Some days
after visiting the spa, whilst in the incubation period for Legionella Mrs Clarke became ill, was
admitted to the Doncaster Royal Infirmary on the 22nd March where she passed away on the
27th. Her cause of death was myocardial infarction due to Legionella Pneumonia. Testing of
samples taken from Mrs Clarke and water samples from the spa revealed identical isolates in
terms of the Legionella strain and a Consultant Clinical Scientist said that the isolates were
indistinguishable.
During the course of the inquest reference was made to ACOP L8 which deals with Legionella
control measures where it was noted that there was no advice or guidance provided with regard
to effective cleaning of fixed shower heads. During the course of the evidence I also heard that
fixed shower heads (of the type used at the Elements Spa where Legionella was detected) have
become increasingly common over the recent years. I am informed that they are popular in
premises such as spas, health centres etc and to reduce the incidence of theft they are often
fixed and cannot be dismantled for cleaning by way of immersion in appropriate liquid. Given
that Legionella was detected in the fixed head of the rain shower of the Elements Spa, the
evidence I heard in connection with this and the increased incidents of these types of showers
being used in public places it would seem prudent to give consideration as to how such fixed
shower heads can be effectively cleaned to reduce the risk of Legionella and to incorporate
appropriate guidance
Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS
Tel 01302 320844 | Fax 01302 364833
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In my
opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it
is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
(1) There is no guidance for effective cleaning of fixed shower heads increasingly used in private
and public leisure facilities.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the power
to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by
06 March 2015. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to
Elements Spa, Rotherham MBC, and Water Treatment Products Ltd. I have also sent it to who
may find it useful or of interest.
and to the following Interested Persons:
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He
may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the
release or the publication of your response by the Chief Coroner.
9
Dated 09 February 2015
Signature_________________________
Senior Coroner for South Yorkshire (East District)
Coroner's Court and Office, Doncaster Crown Court, College Road, Doncaster, DN1 3HS
Tel 01302 320844 | Fax 01302 364833
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Doncaster Metropolitan Borough Council a Ms N J Mundy Contact: Po Senior Coroner Tel: South Yorkshire (East) District Fax: po Doncaster Crown Court a. College Road E-mail: po Doncaster Web: www.doncaster.gov.uk DN1 3HS Our Ref: Date: 24" March 2015 Dear Ms Mundy, Re: Margaret Elsie CLARKE (Deceased) Consumer Protection Act 1987 General Product Safety Regulations 2005 Further to my recent letter acknowledging receipt of a copy of your report following the unfortunate death of Mrs Margaret Clarke from i the Health and Safety Executive | have now had an opportunity to consider the matter. This Authority has a duty to enforce the provisions of the Consumer Protection Act 1987 (CPA87) and the General Product Safety Regulations 2005 (GPSR). These two pieces of legislation work together to establish a regime to ensure that consumers may purchase products in the knowledge that they should be reasonably safe when used in the manner intended. The CPA87 Part Il firstly gives the Secretary of State the power to make regulations regarding specific goods, or classes of goods, in order to ensure that when supplied those goods are safe. An example of this is The Toys (Safety) Regulations 2011 which regulate certain aspects regarding playthings for children. Where there are specific regulations such as these, the supply of a product which does not conform to the requirements of the regulations is an offence by virtue of section 12 of the Act. | attach a list of the regulations currently in force under this legislation as Appendix 1 to this letter. You will notice that there are no regulations that apply to showerheads or indeed plumbing products more generally. The only solution to the problem under this legislation would be for the Secretary of State to make regulations relating to these products under Section 11 of the Act. The GPSR fill in where specific regulations do not exist. It places a general requirement on manufacturers, or in the case of imported goods their representative within the European Union, to only place on the market products which are safe. Contravention of the requirement is an offence. A safe product is defined as: Doncaster Council Civic Office, Waterdale, Doncaster DN1 3BU A product which, under normal or reasonably foreseeable conditions of use including duration and, where applicable, putting into service, installation and maintenance requirements, does not present any risk or only the minimum risks compatible with the product's use, considered to be acceptable and consistent with a high level of protection for the safety and health of persons. In determining the foregoing, the following shall be taken into account in particular— (a) the characteristics of the product, including its composition, packaging, instructions for assembly and, where applicable, instructions for installation and maintenance, (b) the effect of the product on other products, where it is reasonably foreseeable that it will be used with other products, (c) the presentation of the product, the labelling, any warnings and instructions for its use and disposal and any other indication or information regarding the product, and (d) the categories of consumers at risk when using the product, in particular children and the elderly. The feasibility of obtaining higher levels of safety or the availability of other products presenting a lesser degree of risk shall not constitute grounds for considering a product to be a dangerous product; However “product” is defined as: A product which is intended for consumers or likely, under reasonably foreseeable conditions, to be used by consumers even if not intended for them and which is supplied or made available, whether for consideration or not, in the course of a commercial activity and whether it is new, used or reconditioned and includes a product that is supplied or made available to consumers for their own use in the context of providing a service. This leaves a couple of difficulties. Firstly, there is the question of whether a shower head which requires permanent installation, rather than a detachable hose and head, is intended for consumers. It is much more likely that it is intended to be supplied to the plumbing trade and therefore outside the remit of the regulations. Secondly, | have doubts about whether it is the shower head itself that is unsafe. Although my understanding of problems with Legionnaires disease is very limited, | believe it is more to do with the installation as a whole, together with the management, use and cleaning of the water system rather than the individual component. Legionella levels take time to build up, needing the appropriate environment to multiply in order to cause a problem. Then a situation is required where the contaminated water is atomised and introduced to the person. It is not necessarily the showerhead where the infection has built up — the showerhead is merely the vector, and therefore cleaning the showerhead alone would not be a reliable remedy. Given an infected supply the same could happen in a variety of situations and cause otherwise perfectly safe products to become potential sources of infection. If this is the case it is not the design of the showerhead that needs consideration, but the maintenance of the water system as a whole. Doncaster Council Civic Office, Waterdale, Doncaster DN1 3BU The issue of maintaining water systems is already addressed in the HSE ACOP L8 as you have pointed out. And | note that paragraph 2(a) already identifies showers as a potential risk and the information relating to low risk situations referring to “no showers”. It would seem to me, particularly if | am correct that cleaning the showerhead alone could be ineffective, that the appropriate response to this situation would be for the HSE to review the guidance that they publish regarding Legionnaires disease to consider if greater emphasis needs to be put on showers being a suitable vector, and the required installation and maintenance of shower systems. | have copied a on this letter to allow him to comment further. | hope that you find this response helpful and it is formulated given the facts available to us, if you feel you have any other pertinent information to inform our conclusions please feel free to contact me should you feel | can assist any further. Yours sincerel Senior Trading Standards Officer ce. f.a.o. HM Inspector of Health & Safety Health & Safety Executive Group 10 Foundry House 3 Millsands Riverside Exchange Sheffield S3 8NH Doncaster Council Civic Office, Waterdale, Doncaster DN1 3BU
Health and Safety Executive Ms N J Mundy Senior Coroner Coroner’s Court and Office Doncaster Crown Court College Road Doncaster DN1 3HS Date 9 March 2015 Your Dear Ms Mundy Field Operations Directorate Scotland and Northern England Division Health and Safety Executive Group 10 Foundry House 3 Millsands Riverside Exchange Sheffield $3 8NH Tel: — Manager RE: REGULATION 28 REPORT FOR MARGARET ELSIE CLARKE, (DECEASED) | refer to your letter of 9 February 2015 concerning the above death involving legionella at Elements Spa, Rotherham which involved a shower head which was used at the premises. You expressed concern that future deaths could occur unless fixed shower heads can be effectively cleaned to reduce the risk and to incorporate advice on cleaning into guidance. Shower heads are designed, manufactured and supplied under the General Product Safety Regulations 2005. HSE has no enforcement powers under these Regulations so | have passed your letter to your local Trading Standards Department at Doncaster Council, Civic Office, Waterdale, Doncaster, DN1 3BU. Yours sincerely HM Principal Inspector of Health and Safety
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