Prisoner's Legionnaire Death Slammed

The Prison Service has been strongly criticised for its failures in relation to an inmate's death after he was exposed to a deadly bacteria whilst a patient in its Healthcare Unit.

The Health and Safety Executive for Northern Ireland (HSENI) called the Northern Ireland Prison Service (NIPS) to account over a case of Legionnaires' Disease at Magilligan after a prisoner died in February 2007.

HSENI conducted a thorough and detailed investigation to determine the likely source of exposure and discovered high levels of legionella bacteria in the hot and cold water system.

Although the victim had underlying health conditions, HSENI found the Approved Code of Practice for controlling legionella bacteria in water systems had not been followed.

"Whilst this is a breach of Article 5 of the Health and Safety at Work (Northern Ireland) Order 1978 no criminal proceedings could be taken against NIPS given its crown immunity," a statement said yesterday, going on to say that HSENI instigated a 'crown censure' against NIPS instead.

Louis Burns, Head of HSENI's Major Investigation Team said: "The system for managing health and safety at H.M.P. Magilligan had not been effective in controlling this well-known risk.

"The standard was far below what is appropriate for a prison," he said, noting that "this case highlights the need for those in charge of premises to properly manage hot and cold water systems so as to minimise the risk from legionella bacteria particularly where vulnerable people may be present".

Speaking after the ruling the Prison Service Director General Robin Masefield said that he accepted the finding but stressed that there were numerous mitigating circumstances.

Mr Masefield said: "The Prison Service regrets the outcome for this prisoner. He was terminally ill and was being cared for in the healthcare unit of Magilligan Prison when he was exposed to infection.

"His weak immune system left him particularly vulnerable and, unfortunately, he became infected with the bacteria when in the healthcare unit," he explained.

"It is clear from the HSENI finding that where more than one body is responsible for the management and oversight of contracts, that clear and accountable reporting procedures need to be in place.

"In this instance the private company which was responsible for the maintenance and inspection of the water treatment programme at the prison were not directly under contract to the Prison Service, but were part of a wider crown estate contract," he continued.

"Unfortunately, where the need for remedial work was identified, as in this case, it proved to be a less than satisfactory arrangement."

Mr Masefield added that since the finding of the legionella bacteria in the Magilligan Healthcare Unit in 2007, the Prison Service had introduced a range of measures to reduce the risk of any reoccurrence.

(BMcC/GK)