“Those who conducted the investigation and root cause analysis on the part of the hospital…”

The coroner’s concerns

This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.

— (1) Those who conducted the investigation and root cause analysis on the part of the hospital did not appreciate that notwithstanding the absence of the specific subgroup of Legionella serotype 1 in the water samples from the ward as compared to samples from the deceased that this was not conclusive as to the ward not being the source of the infection. (2) There was a lack of understanding on the part of the hospital as to how to interpret the results of the microbiological analysis of the water samples and the limitations of testing including the meaning of any results obtained, the teliability which may be placed on those results and any conclusions which may be drawn from those results. (3) As a result of this lack of understanding the hospital misinterpreted the results and conducted their investigation and root cause analysis on a false premise which led them to conclude erroneously that the William Budd ward was not the source of the Legionella infection. (4) The hospital, although responding promptly to the infection, had no procedure in place detailing how the investigation of the cause of a legionella infection should be undertaken. (5) The hospital should put in place an approved procedure for the investigation of any future outbreaks of Legionella infection should they occur. This procedure should describe and define clearly inter alia the nature, limitations and interpretation of the results of any microbiological testing undertaken. (6) The responsibility for putting such a procedure in place should be that of the Director of Infection Prevention and Control who, in drafting the procedure, should seek the support and guidance of appropriate professionals including Public Health England and the Health Safety Executive

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2016-0056

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0