Greg Davies Legionella - A lesson in strategy?

Greg Davies
ems
Legionella - A lesson in strategy?
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
The UK's worst ever outbreak of Legionnaires’ disease
occurred between July and August 2002 at Forum 28,
Barrow in Furness
• 5 to 7 deaths
• 179 confirmed cases
• Many more, ?500+, ill (flu like symptoms)
• Investigation involving CPS, HSE, Cumbrian Police
– Barrow Borough Council and Gillian Beckingham jointly charged
with manslaughter
– Council also charged under section 3 HASW 1974
– Gillian Beckingham also charged under section 7 HASW 1974
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
The UK's worst ever outbreak of Legionnaires’ disease Three to five years on
• Two high profile trials
– March / April 2005
– July / August 2006
• Public meetings following trial verdict (December 2006)
• Ongoing personal injury claims = £millions?
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
“A company’s system of internal control will reflect...
• Control activities;
• Information and communication processes;
• Processes for monitoring the continuing effectiveness
of the system…”
• Systems for assessing and reacting to risk
The Turnbull Report
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Health and safety
A “grudge purchase” or a business imperative?
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Health and safety drivers - Legal
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Health and safety drivers - Moral
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Health and safety drivers – Financial
Barrow judgement August 2006
• Barrow Borough Council - failings “grave in the
extreme”
– Fined £125,000
– Costs £90,000
• Gillian Beckingham (Design Services Manager) “repeated and serious failings”
– Fined £15,000
– Acquitted of manslaughter charges
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Health and safety drivers - financial
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Strategy
• “Perception is strong and sight is weak. In strategy it
is important to see distant things as if they were close
and to take a distanced view of close things”
Miamoto Musashi
• “A dangerous strategy is considering to jump a
chasm in two leaps”
Disraeli
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
• “Contamination of water systems, natural or in
buildings, by Legionella pneumophila is widespread
and in itself harmless.
• For the organism to be dangerous to man, there must
be an opportunity for it to multiply and then become
airborne in the form of an aerosol.”
Sir John Badenoch, 1985
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Policy
• Your statement of intent. It should;
– Identify the requirements you want to comply
with
– Have clear objectives
– Be authorised and signed by senior
management
– Be regularly reviewed
“By definition, a government has no conscience.
Sometimes it has a policy, but nothing more.”
Albert Camus
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Approved Code of Practice L8
• Identification and assessment of the risk
• Managing the risk: management responsibilities,
training and competence
• Preventing or controlling the risk from exposure to
legionella
• Record keeping
• Responsibilities of manufacturers, importers,
suppliers and installers
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Risk Assessment
• Your foundation document must cover all water
systems present
• Identify where exposure can be prevented or needs
to be managed
• A living document and should be reviewed at least
every two years
“There are risks and costs to a program of action. But they are far less than the
longer range risks & costs of comfortable inaction”
John F Kennedy
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Responsibilities
• “ the person on whom the statutory duty falls should
appoint a person or persons to take managerial
responsibility and to provide supervision for the
implementation of precautions”
L8 para 39
“You cannot escape the responsibility of tomorrow by evading
it today”
Abraham Lincoln
BIFM ANNUAL CONFERENCE
Oxford 2007
Chief
Executive
Director
of
Finance
Director
of
Development
Design
Services
Manager
H&S
Officer
Cultural
Services
Venue
Manager
Assistant
Manager
Technical
Services
BIFM ANNUAL CONFERENCE
Oxford 2007
Chief
Executive
Director
of
Finance
Director
of
Development
Design
Services
Manager
H&S
Officer
Cultural
Services
Venue
Manager
Assistant
Manager
Technical
Services
BIFM ANNUAL CONFERENCE
Oxford 2007
Chief
Executive
Director
of
Finance
Director
of
Development
Design
Services
Manager
H&S
Officer
Cultural
Services
Venue
Manager
Assistant
Manager
Technical
Services
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Responsibilities - Also extends to suppliers
• Covers competence, limitations of service and/or
expertise and provision of information as well as;
“to ensure that any deficiencies or limitations
identified in the system or written scheme are made
known to the statutory duty holder or responsible
person”
L8 para 71(d)
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Responsibilities
• If you don’t nominate an overall responsible
person and something goes wrong, the authorities
will be happy to!!
• You can delegate the tasks, you cannot delegate
the responsibility
“You cannot escape the responsibility of tomorrow by evading
it today”
Abraham Lincoln
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Written Scheme – should include
• An up to date plan of all systems
• A description of their safe operation
• The precautions to be taken
• The checks to be carried out
• Remedial actions if the scheme is shown not to be
effective
“Underlying the whole scheme of civilization is the confidence men have in
each other, confidence in their integrity, confidence in their honesty,
confidence in their future.”
Bourke Cockran
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Written Scheme
• A positive legionella sample at the lower limit of
detection (100 cfu/litre) from a system with a volume
of 2500 litres, potentially means a gross
contamination of 250,000 organisms.
• Assuming a 2 hour reproduction rate, a single
legionella bacterium now, could increase to over
16,700,000 in 48 hours
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Record Keeping - should include:
• The persons responsible for the risk
assessment, as well as those managing and
implementing the written scheme
• The significant findings of the risk assessment
• The written scheme itself
• The results of all works undertaken on the
systems
“History is a confused heap of facts.” Lord Chesterfield
“History is a vast early warning system.” Norman Cousins
BIFM ANNUAL CONFERENCE
Oxford 2007
Data
Month/
Year
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
1993
104
103
103
103
104
103
104
105
104
103
103
105
1994
104
105
104
103
103
104
106
105
105
104
104
103
1995
105
106
104
103
104
105
105
104
104
103
103
104
1996
105
106
104
104
103
105
105
104
103
105
104
106
1997
106
106
104
104
103
104
105
104
103
104
103
106
1998
106
104
104
103
104
105
106
106
104
103
104
103
1999
103
103
103
103
105
105
104
104
103
104
103
104
2000
103
106
103
106
104
103
104
103
104
103
104
105
2001
105
104
104
104
103
105
104
104
104
103
103
104
2002
104
103
103
104
103
103
104
104
103
103
104
103
BIFM ANNUAL CONFERENCE
Oxford 2007
Information
Month/
Year
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
1993
104
103
103
103
104
105
104
105
104
103
103
105
1994
104
105
104
103
103
104
106
103
103
104
104
103
1995
105
106
104
103
104
105
105
104
104
103
103
104
1996
105
106
104
104
103
105
105
104
103
105
104
106
1997
106
106
104
104
103
104
105
104
103
104
103
106
1998
106
104
104
103
104
105
106
104
104
103
104
103
1999
103
103
103
103
105
105
104
104
103
104
103
104
2000
103
106
103
104
106
103
106
103
104
103
104
105
2001
105
104
104
104
103
105
104
104
104
103
103
104
2002
104
103
103
104
103
103
104
104
103
103
104
103
BIFM ANNUAL CONFERENCE
Oxford 2007
Knowledge
Month/
Year
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
1993
104
103
103
103
104
105
104
105
104
103
103
105
1994
104
105
104
103
103
104
106
103
103
104
104
103
1995
105
106
104
103
104
105
105
104
104
103
103
104
1996
105
106
104
104
103
105
105
104
103
105
104
106
1997
106
106
104
104
103
104
105
104
103
104
103
106
1998
106
104
104
103
104
105
106
104
104
103
104
103
1999
103
103
103
103
105
105
104
104
103
104
103
104
2000
103
106
103
104
106
103
106
103
104
103
104
105
2001
105
104
104
104
103
105
104
104
104
103
103
104
2002
104
103
103
104
103
103
104
104
103
103
104
103
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Training
• All people involved in the management should
be trained in the general requirements
• Those undertaking day to day activities
should have additional training in these areas.
This should be system specific
• Levels of competency should be assessed
for 3rd parties (UKAS/LCA/other)
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
• “While the bacterium which causes Legionnaires’
disease probably cannot be totally eradicated from
water systems, the circumstances which encourages
growth are known and it can be controlled”
House of Commons Employment Committee 1988
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Since Jan 2005 there have been at least 44 reported
outbreaks worldwide
UK since August 2006, outbreaks reported in;
• Sunderland - August
• Shropshire - August
• East Anglia - September
• Kent - October
• Somerset - November
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Summaries of HSE enforcement notices;
• “Suitable and sufficient legionella risk
assessment not undertaken” – JohnsonDiversey
UK Ltd
• “Inadequate risk assessment” – Sandvik
Coromant UK Ltd
• “A legionella “responsible” person and deputy
not identified” – Burton Hospitals NHS Trust
• “No written scheme” – Dr M Ali (Nursing Home)
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
• “Failure to manage hot and cold water services” –
Basildon & Thurrock Hospitals NHS Trust
• “Failure to take suitable and sufficient steps to
control risk of legionella” – Mefuka (UK) Ltd
• “No provision for record keeping” – TVR
Engineering Ltd
• “Notice issued following legionella outbreak at
barracks…” MOD Army
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
“A company’s system of internal control will reflect...
• Control activities;
• Information and communication processes;
• Processes for monitoring the continuing effectiveness
of the system…”
• Systems for assessing and reacting to risk
The Turnbull Report
BIFM ANNUAL CONFERENCE
Oxford 2007
Legionella – A lesson in strategy?
Thank you for your time
“STRATEGY is; A style of thinking, a conscious and
deliberate process, an intensive implementation
system, the science of insuring future success.”
Pete Johnson
BIFM ANNUAL CONFERENCE
Oxford 2007
Panel Discussion
Tuesday 27th March
How successful has the UK’s FM profession
been in integrating facilities management into business?
Alistair Craig
Cathy Hayward
BIFM ANNUAL CONFERENCE
Oxford 2007
Nigel Gooding
Phil Jones
Jamie Reynolds