Recurring concern

Inadequate control of waterborne pathogen risks in healthcare water systems

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First reported 1 Apr 2019•Latest report 14 Nov 2022

Definition

What this concern includes

Includes failures in healthcare or care-premises water-system safety controls specifically intended to prevent, detect or control waterborne pathogen risks, including understanding pathogen entry or colonisation pathways and water-system design features such as pipe runs, usage patterns and hot- and cold-water separation.

Not included

Excludes generic infection-prevention, environmental-cleaning or microbiology deficiencies that are not specifically tied to water-system risks.
Excludes Legionella testing, reporting or outbreak-investigation failures when the water-system control itself is adequate and the deficiency is limited to detection or investigation.
Excludes patient treatment or clinical infection-management failures after a waterborne infection has been identified.
Excludes non-healthcare water systems and general water-quality concerns without a material healthcare or care-premises safety context.

Reports: 2
Individual concerns: 4
Date range: 2019–2022
Stated actions: 4

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission1

Department of Health and Social Care1

Royal Institute of British Architects1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

14 Nov2022
Cambridgeshire and Peterborough
Concerns raised3
1. Continuing hospital water-associated transmission of M abscessus
2. Incomplete understanding of M abscessus entry into and colonisation of hospital water systems
3. Lack of guidance on identification and control of M abscessus in hospital water systems
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Commission a review of HTM 04-01 covering immunosuppressed patients, nontuberculous mycobacteria, testing and additional protective measures.
  Stated by NHS EnglandStated in progress
2. Action
  Write and publish a technical bulletin containing appropriate HTM 04-01 amendments to keep the guidance accurate and up to date.
  Stated by NHS EnglandStated planned
Respondent positions 2
1. Position
  NHS England, as owner of the relevant guidance, is responsible for responding to the concerns about hospital water systems.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  HTM 04-01 already provides guidance on controlling mycobacteria, including measures relevant to M. abscessus as an atypical mycobacterium.
  Stated by NHS EnglandDisputes the concern
AI-generated summary

Karen Lesley Starling and Anne Edith Martinez · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Karen Lesley Starling and Anne Edith Martinez underwent lung transplant procedures at the new Royal Papworth Hospital and subsequently contracted hospital-acquired M abscessus infections, in consequence of which they died. The report identifies concerns that existing hospital water-system guidance provided no relevant guidance on mycobacteria or M abscessus, did not require routine testing or specify acceptable levels, and did not address additional measures for immunosuppressed patients or the risks associated with new hospitals.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Continuing hospital water-associated transmission of M abscessus
Wider context from the report
“1. It is recognised that M abscessus poses a risk of death to those who are immunosuppressed. That will be so for many patients at specialist hospitals such as Royal Papworth and more generally for hospital patients. To date, 34 patients at Royal Papworth have contracted M abscessus from the hospital’s water. Cases continue to be reported, albeit at a declining rate; ”
Source location
Karen Lesley Starling and Anne Edith Martinez · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Incomplete understanding of M abscessus entry into and colonisation of hospital water systems
Wider context from the report
“2. There is an incomplete understanding of how M abscessus may enter and/or colonise a hospital water system; ”
Source location
Karen Lesley Starling and Anne Edith Martinez · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidance on identification and control of M abscessus in hospital water systems
Wider context from the report
“3. Health Technical Memorandum 04-01 Safe Water in Healthcare Premises was published by the Department of Health in 2016. It is concerned with the design, installation, commissioning and operation of hospital water systems. This guidance requires urgent review and amendment, whether by way of an Addendum or otherwise because: a. It is a key document for hospital estate managers and Water Safety Groups; b. It purports to provide comprehensive guidance on waterborne bacteria; c. However, it provides no relevant guidance in relation to mycobacteria and none in relation to M abscessus. It provides no guidance on the identification and control of M abscessus. It does not require routine testing for mycobacteria, including M abscessus or provide guidance on acceptable levels (if any). Compliance with the guidance does not identify or guard against the risk from M abscessus; d. It provides no guidance on any additional measures that may be required in respect of “augmented care” patients, including those who are immunosuppressed; e. It is not in any event consistent with British Standard BS 8580-2:2022 on Water Safety. ”
Source location
Karen Lesley Starling and Anne Edith Martinez · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Commission a review of HTM 04-01 covering immunosuppressed patients, nontuberculous mycobacteria, testing and additional protective measures.

Verbatim wording from the response
“Commissioned review”

Source location
Response from NHS England
Page 5 · response
Published 21 November 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Write and publish a technical bulletin containing appropriate HTM 04-01 amendments to keep the guidance accurate and up to date.

Verbatim wording from the response
“Any suggested amendments to HTM 04-01 which derive from this review will be carefully considered, and appropriate amendments will be written into a technical bulletin, which in turn will be published to ensure HTM 04-01 is accurate and up to date. The aim is to publish the technical bulletin by the Spring.”

Source location
Response from NHS England
Page 6 · response
Published 21 November 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England, as owner of the relevant guidance, is responsible for responding to the concerns about hospital water systems.

Verbatim wording from the response
“Health Technical Memorandums are owned by NHS England (NHSE) and they are the correct organisation to respond to the concerns you raised in your report.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 21 November 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
HTM 04-01 already provides guidance on controlling mycobacteria, including measures relevant to M. abscessus as an atypical mycobacterium.

Verbatim wording from the response
“HTM 04-01 provides guidance on the legal requirements, design applications, maintenance and operations of hot and cold-water supply storage and distribution systems in all types of healthcare premises. It also provides advice and guidance on the control and management of the risk posed by water borne pathogens within a healthcare setting such as Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Mycobacteria as well as Legionella.”

Source location
Response from NHS England
Page 5 · response
Published 21 November 2022
Open published response
1 Apr2019
Wiltshire and Swindon
Concerns raised1
1. Failure of care-home and healthcare-premises architects to take water safety into account
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Develop and publish a concise member resource explaining the need to consider water safety when coordinating care-home and healthcare-building design.
  Stated by Royal Institute of British ArchitectsStated planned
2. Action
  Publish the interim Raising the Bar report proposing enhanced competence levels across relevant building and life-safety professions.
  Stated by Construction Industry CouncilStated planned
Respondent positions 2
1. Position
  Education, training, accreditation and continuing professional development for relevant designers fall outside the council’s direct remit and authority.
  Stated by Construction Industry CouncilOutside remit
1. Position
  Relevant professional and training registration bodies are responsible for providing the suggested education and training.
  Stated by Construction Industry CouncilRedirects responsibility
AI-generated summary

Andrew Robert Frank Clegg · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Andrew Robert Frank Clegg, a 56-year-old vulnerable individual with corticobasilar degeneration, lived in a specialist care home where problems with the water system allowed legionella bacteria to colonise it. He was infected and died from legionella pneumonia, which the inquest jury concluded resulted from an accident. Concerns included inadequate water-safety design in care homes and insufficient inspector training to identify potential legionella risks.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of care-home and healthcare-premises architects to take water safety into account
Wider context from the report
“1. 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. ”
Source location
Andrew Robert Frank Clegg · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and publish a concise member resource explaining the need to consider water safety when coordinating care-home and healthcare-building design.

Verbatim wording from the response
“In responding to your concerns, the RIBA intends to develop a concise knowledge resource to explain to our members the need to consider water safety, particularly in coordinating the design of care homes and healthcare buildings. We intend to publish this as an article by the end of July to raise awareness of the water safety issues highlighted in your report.”

Source location
2019-0108-Responses
Page 4 · response
Published 9 June 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publish the interim Raising the Bar report proposing enhanced competence levels across relevant building and life-safety professions.

Verbatim wording from the response
“Our report – Raising the Bar – proposes enhanced competence levels for Engineers, Installers, Fire Engineers, Fire Risk Assessors, Fire Safety Enforcement Officers, Building Control, Building Designers (including Architects), Building Safety Managers, Site Supervisors, Project Managers, Procurement and Products; and has been written with their direct participation and willingness to implement the new competence frameworks. The interim report is due to be published for consultation at the end of this month but, having worked closely with MHCLG and the Home Office throughout, the proposed recommendations dovetail with those included in Building A Safer Future: Proposals for reform of the building safety system.”

Source location
2019-0108-Responses
Page 7 · response
Published 9 June 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Education, training, accreditation and continuing professional development for relevant designers fall outside the council’s direct remit and authority.

Verbatim wording from the response
“The first matter to report in response is that the Construction Industry Council does not have any locus or authority over the education, training, accreditation or continuing professional development of architects, construction (or building services) engineers or others designing water systems for care homes. And so, the particular action that you suggest in relation to providing relevant education and training for architects, construction (or building services) engineers or others designing water systems in this regard, is not within our direct remit but those of the relevant professional and training registration bodies. We will, of course, do what we can to encourage them to take the action suggested.”

Source location
2019-0108-Responses
Page 6 · response
Published 9 June 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Relevant professional and training registration bodies are responsible for providing the suggested education and training.

Verbatim wording from the response
“The first matter to report in response is that the Construction Industry Council does not have any locus or authority over the education, training, accreditation or continuing professional development of architects, construction (or building services) engineers or others designing water systems for care homes. And so, the particular action that you suggest in relation to providing relevant education and training for architects, construction (or building services) engineers or others designing water systems in this regard, is not within our direct remit but those of the relevant professional and training registration bodies. We will, of course, do what we can to encourage them to take the action suggested.”

Source location
2019-0108-Responses
Page 6 · response
Published 9 June 2019
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Continuing hospital water-associated transmission of M abscessus

Incomplete understanding of M abscessus entry into and colonisation of hospital water systems

Lack of guidance on identification and control of M abscessus in hospital water systems

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure of care-home and healthcare-premises architects to take water safety into account

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 2

Respondent positions 2

Actions described in response 2

Respondent positions 2