HSE investigation following the death of an inmate
The Health and Safety Executive (HSE) prosecuted Amey Community Limited, which was responsible for facilities management services at HMP Lincoln, following the death of 71-year-old inmate Graham Butterworth on 5 December 2017. He die dafter contracting Legionnaires’ disease.
Water samples taken from his cell and nearby shower blocks tested positive for legionella bacteria shortly after his death. An HSE investigation revealed that Amey Community Limited had failed to act on a risk assessment completed in2016, had no written scheme for preventing or controlling legionella, and had failed to monitor and maintain appropriate water temperatures during the critical period in October and November 2017. This allowed bacteria to multiply rapidly.
On 3 December2024, the company pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc. Act 1974 and was fined £600,000 plus £15,186.85 in costs at Lincoln Magistrates’ Court.
"There is a legal duty to keep workers and inmates safe in prisons," said HSE Inspector Stacey Gamwell. "Companies such as Amey Community Limited need to ensure they have identified any risk of legionella and have suitable and sufficient arrangements in place."
Why is the effective management of legionella important?
Legionella is a type of bacteria commonly found in natural water sources but can also thrive in artificial water systems — particularly when water is stagnant and temperatures are between20°C and 45°C. When inhaled as droplets or mist, legionella can cause Legionnaires’ disease, a serious and potentially fatal form of pneumonia.
At-risk locations include:
- Showers, taps, and hot water tanks
- Cooling towers and evaporative condensers
- Spa pools and hydrotherapy equipment
- Misting systems, fountains, and decorative water features
- Infrequently used outlets and emergency showers
These systems, if not properly managed, can create ideal environments for legionella growth. The bacteria is particularly dangerous to those with weakened immune systems or respiratory conditions.
The lessons to be learnt about effective legionella risk management
Property owners, managers, landlords, and facilities teams have a legal duty under the Health and Safety at Work etc. Act 1974 and the Control of Substances Hazardous to Health (COSHH) Regulations 2002 to protect building users from preventable risks — including legionella.
A failure to comply not only jeopardises health and lives, but also results in substantial legal, reputational and financial consequences, as demonstrated by this recent case. Importantly, responsibility cannot be outsourced. Even if water system maintenance is contracted out, the duty to ensure compliance remains with the duty holder — be it the property manager, landlord or owner.
To avoid breaches, building safety managers must ensure they:
- Carry out legionella risk assessments
- Act on the findings with documented control measures
- Maintain safe water temperatures
- Flush infrequently used outlets
- Regularly monitor, inspect and record water system conditions
How to reduce the risk of legionella in your properties
Effective legionella management means going beyond ticking boxes. It involves a proactive, systematic approach that includes:
- ✅ Regular risk assessments: Evaluate all water systems — including commonly overlooked ones such as fire suppression systems and decorative fountains.
- ✅ Written schemes of control: Set out responsibilities, control methods and schedules for maintenance and monitoring.
- ✅ Water temperature control: Keep hot water above 50°C and cold water below 20°C to prevent bacteria growth.
- ✅ Flushing and cleaning: Regularly flush unused outlets and clean water tanks, pipework, and filters.
- ✅ Monitoring and documentation: Record temperatures, inspections, and maintenance actions to demonstrate compliance.
- ✅ Expert support: Use certified specialists like Summit Environmental for legionella sampling, testing, and control strategy development.
Whether you manage residential blocks, education facilities, leisure venues, or commercial property, legionella risk is real — but entirely preventable with the right knowledge and actions.
The cost of ignoring legionella risk isn’t just financial — it’s a matter of life and death.
For expert support to maintain the safety of your facilities, get in touch
