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| Version 2 | Version 3 |
|---|---|
| 'Errors' led to Legionella deaths | 'Errors' led to Legionella deaths |
| (about 5 hours later) | |
| A catalogue of "basic failings" led to a Legionnaires' disease outbreak that killed seven people, a report says. | A catalogue of "basic failings" led to a Legionnaires' disease outbreak that killed seven people, a report says. |
| Another 180 people were infected in Barrow, Cumbria, in 2002 because of a faulty air conditioning system at the council-run Forum 28 arts centre. | Another 180 people were infected in Barrow, Cumbria, in 2002 because of a faulty air conditioning system at the council-run Forum 28 arts centre. |
| Poor communication at Barrow Borough Council was to blame, said the Health and Safety Executive (HSE). | Poor communication at Barrow Borough Council was to blame, said the Health and Safety Executive (HSE). |
| The council said it was unable to comment due to an internal disciplinary process and ongoing litigation. | The council said it was unable to comment due to an internal disciplinary process and ongoing litigation. |
| An independent inquiry into the outbreak, carried out in 2006, found safety documents had been thrown away. | An independent inquiry into the outbreak, carried out in 2006, found safety documents had been thrown away. |
| On Tuesday the inquiry's independent chairman Colin Pickthall told the BBC: "The guidelines on how to avoid legionella are readily available then, as now. They weren't used, they weren't disseminated around the council. | On Tuesday the inquiry's independent chairman Colin Pickthall told the BBC: "The guidelines on how to avoid legionella are readily available then, as now. They weren't used, they weren't disseminated around the council. |
| It was quite obvious that communication at the council was non-existent and the chain of command and duty of care completely failed Andy Macauley, Grandson of victim | |
| "They were put in bins or they were put in files." | "They were put in bins or they were put in files." |
| The errors could have been "easily prevented", said the HSE's report, which drew upon the inquiry's findings. | The errors could have been "easily prevented", said the HSE's report, which drew upon the inquiry's findings. |
| Barrow Council was later cleared of corporate manslaughter following the deaths, but fined £125,000 for breaching health and safety laws. | Barrow Council was later cleared of corporate manslaughter following the deaths, but fined £125,000 for breaching health and safety laws. |
| Andy Macauley, whose grandfather Richard died in the outbreak, said: "It was quite obvious that communication at the council was non-existent and the chain of command and duty of care completely failed. | |
| "The £125,000 fine will have been nothing more than an inconvenience to the council and will have had little impact on their budget." | |
| During July and August 2002, visitors to Forum 28 were exposed to Legionella bacterium spilling out from the air conditioning unit. | During July and August 2002, visitors to Forum 28 were exposed to Legionella bacterium spilling out from the air conditioning unit. |
| The bacteria had been able to breed because the system was not properly cleaned and the temperature inside was not controlled. | The bacteria had been able to breed because the system was not properly cleaned and the temperature inside was not controlled. |
| 'Fateful coincidences' | 'Fateful coincidences' |
| The HSE report comes after a lengthy investigation and a series of public meetings in Barrow last December. | The HSE report comes after a lengthy investigation and a series of public meetings in Barrow last December. |
| It concludes: "The number of fateful 'coincidences' involved was scarcely credible. | It concludes: "The number of fateful 'coincidences' involved was scarcely credible. |
| "Such basic failings should not have occurred and, sadly, these failures could have been easily prevented." | "Such basic failings should not have occurred and, sadly, these failures could have been easily prevented." |
| Investigators said communication between staff responsible for the air conditioning system at the borough council was poor and that they failed to act when concerns were raised. | Investigators said communication between staff responsible for the air conditioning system at the borough council was poor and that they failed to act when concerns were raised. |
| They also failed to carry out a risk assessment and to properly manage contractors to ensure the system was adequately maintained, the report adds. | They also failed to carry out a risk assessment and to properly manage contractors to ensure the system was adequately maintained, the report adds. |
| Families' anger | Families' anger |
| The report also highlights the role of the council's design services manager, Gillian Beckingham. | The report also highlights the role of the council's design services manager, Gillian Beckingham. |
| Last year she was convicted of health and safety breaches at Preston Crown Court, but cleared of manslaughter. | Last year she was convicted of health and safety breaches at Preston Crown Court, but cleared of manslaughter. |
| She had, the court heard, not properly maintained the contracts that provided for the upkeep of the air conditioning unit. | She had, the court heard, not properly maintained the contracts that provided for the upkeep of the air conditioning unit. |
| The HSE said Ms Beckingham's failures were "more significant than others". | The HSE said Ms Beckingham's failures were "more significant than others". |
| Richard Macauley, 89, Wendy Milburn, 56, Georgina Sommerville, 54, Harriet Low, 74, Elizabeth Dixon, 80, June Miles, 56, and Christina Merewood, 55, all died in the outbreak. | Richard Macauley, 89, Wendy Milburn, 56, Georgina Sommerville, 54, Harriet Low, 74, Elizabeth Dixon, 80, June Miles, 56, and Christina Merewood, 55, all died in the outbreak. |
| Their families have repeatedly called for council chief executive Tom Campbell to resign. | Their families have repeatedly called for council chief executive Tom Campbell to resign. |
| An inquest into the deaths is to take place in June. | An inquest into the deaths is to take place in June. |