Recurring concern

Unreliable Legionella infection detection and investigation

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First reported 27 Apr 2015•Latest report 12 Feb 2016

Definition

What this concern includes

Includes failures of controls specifically dedicated to detecting, rapidly testing, reporting, investigating or interpreting evidence about Legionella infections or outbreaks, including availability of rapid testing and reporting services and approved investigation procedures.

Not included

  • Excludes general hospital water-safety, infection-control or microbiology deficiencies unless they are explicitly tied to Legionella detection or investigation.
  • Excludes failures concerning other waterborne organisms, including mycobacteria or M. abscessus, unless the assertion also explicitly concerns Legionella.
  • Excludes treatment or clinical-management failures after Legionella infection has been reliably detected and investigated.
  • Excludes generic testing, reporting, documentation or policy deficiencies that are not dedicated to the Legionella detection and investigation process.
Reports
2

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2015–2016

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Betsi Cadwaladr University LHB1
Care Quality Commission1
Glan Clwyd Hospital1
NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board1
Royal United Hospitals Bath NHS Foundation Trust1

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.

  1. Avon

    AI-generated summary

    Mr. Terence Brooks · 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

    Mr. Terence Brooks, who was being treated for acute myeloid leukaemia, developed Legionella pneumophila pneumonia and died on 23 July 2015. The report raised concerns that the hospital misinterpreted microbiological testing, conducted its investigation on a false premise, and had no procedure for investigating the cause of a Legionella infection.

    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

    Lack of a procedure for investigating the cause of Legionella infection

    Wider context from the report

    “(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. ”

    Source location

    Mr. Terence Brooks · 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

    Failure to correctly interpret microbiological water-sample results and testing limitations

    Wider context from the report

    “(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 reliability 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 incorrectly that the William Budd ward was not the source of the Legionella infection. ”

    Source location

    Mr. Terence Brooks · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. North Wales (East and Central)

    AI-generated summary

    Sally Ellison · 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

    Sally Ellison contracted legionella while on holiday in Tunisia in mid-May 2012 and died on 1 June 2012 from cardiac arrest, multi-organ failure and legionella pneumonia. Concerns were raised that testing for legionella was not undertaken until 31 May, with confirmation on 1 June, and that this may have delayed optimal treatment; the report also identified the need for earlier testing and a rapid testing and reporting service.

    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

    Unavailability of a rapid testing and reporting service for legionella

    Wider context from the report

    “2. Not only should consideration therefore be given to undertaking tests at an earlier stage but there should also be available to the hospital a rapid testing and reporting service, either preferably a service within North Wales or utilising options within organisations geographically closer and more accessible than those in Cardiff. ”

    Source location

    Sally Ellison · Prevention of Future Deaths report
    Page 1 · 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

    Failure to undertake timely urine testing for legionella

    Wider context from the report

    “1. That although it was clear upon her admission to Glan Clwyd on the 29th of May 2012 at around 16.00 hours, that she was suffering from a severe form of Community Acquired Pneumonia, and that this was recognised as being an atypical pneumonia that same evening, no urine sample was sent for analysis until overnight on the 31st of May with the confirmation of it being positive for legionella coming on the morning of the 1st of June. It is the case that treatment was already being given for the possibility of legionella from the 30th of May, but this was not against a confirmed diagnosis and therefore optimal treatment may have been delayed. ”

    Source location

    Sally Ellison · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026