Margaret Elsie Clarke · Prevention of Future Deaths report

On Monday 5th January 2015 I commenced an investigation into the death of Margaret Elsie Clarke, age 77. The investigation concluded at the end of the inquest on Friday 9th January 2015. The conclusion of the inquest was 1a. Myocardial Infarction 1b. Legionella Pneumonia. It was the unanimous conclusion of the Jury that on the 14th March 2013 Mrs Margaret Elsie Clarke, date of birth 19.10.1935 attended Elements Spa, Rotherham, where she contracted Legionella Pneumophilia, this led to her being admitted to Doncaster Royal Infirmary where she died on 27th March 2013.

Mrs Margaret Elsie Clarke and her husband visited the Elements Spa in Rotherham on the 14th March 2013 where they used a number of their facilities including a rain shower. Some days after visiting the spa, whilst in the incubation period for Legionella Mrs Clarke became ill, was admitted to the Doncaster Royal Infirmary on the 22nd March where she passed away on the 27th. Her cause of death was myocardial infarction due to Legionella Pneumonia. Testing of samples taken from Mrs Clarke and water samples from the spa revealed identical isolates in terms of the Legionella strain and a Consultant Clinical Scientist said that the isolates were indistinguishable.

During the course of the inquest reference was made to ACOP L8 which deals with Legionella control measures where it was noted that there was no advice or guidance provided with regard to effective cleaning of fixed shower heads. During the course of the evidence I also heard that fixed shower heads (of the type used at the Elements Spa where Legionella was detected) have become increasingly common over the recent years. I am informed that they are popular in premises such as spas, health centres etc and to reduce the incidence of theft they are often fixed and cannot be dismantled for cleaning by way of immersion in appropriate liquid. Given that Legionella was detected in the fixed head of the rain shower of the Elements Spa, the evidence I heard in connection with this and the increased incidents of these types of showers being used in public places it would seem prudent to give consideration as to how such fixed shower heads can be effectively cleaned to reduce the risk of Legionella and to incorporate appropriate guidance

(1) There is no guidance for effective cleaning of fixed shower heads increasingly used in private and public leisure facilities.