Coroners Report Comments from Death in Care Home

A Jury concluded earlier this year that a Man who died in a relatively newly constructed Fordingbridge care home died from Legionella pneumonia.  A recent regulation 28 report from the Coroner, Nicholas Rheinberg, had two significant concerns to raise with two separate organisations.    


The MATTERS OF CONCERN are as follows. –  


1.     To the Royal Institute of British Architects (RIBA) - Expert evidence suggested that architects designing care homes and healthcare premises, rarely take into account the need for water safety. In combating the risk of a proliferation of legionella bacteria, it is desirable, among other things, to design a water system with short pipe runs and with areas of maximum water usage established at the end of pipe runs to ensure a regular flushing of the pipework. Legionella bacteria, flourishing as it does at temperatures in excess of 20 degrees centigrade, precautions need to be taken to avoid heat exchange between hot and cold-water pipes, calling for cold-water pipes to be set at a distance from hot-water pipes rather than being run in parallel.    


2.     To the Care Quality Commission (CQC) - Care homes and other healthcare premises are regularly inspected by the Care Quality Commission. In recent years the inspection regime has included a duty on inspectors to check on water safety. Expert evidence at the inquest suggested that inspectors lacked training to help them identify risks relating to potential legionella infection.      


In the Coroner’s opinion, action should be taken to prevent future deaths and it is believed that the two organisations named above have the power to take such action. Specifically, consideration might be given towards providing relevant education and training.