Case Studies
When Compliance Fails
Legionella is not only a health risk, it’s a legal one. Across the UK, companies and individuals have faced criminal proceedings, heavy fines, and even prison sentences for failing to comply with water safety regulations such as ACOP L8, HSG274, and HTM-04-01.
The case studies below highlight real examples where poor management, inadequate training, or neglect of water systems led to serious consequences, including outbreaks, fatalities, and significant financial and reputational damage.
These examples serve as a reminder that compliance is not optional, it’s a legal duty. With the right guidance and ongoing support, these risks can be managed and avoided.
Company Fined for Death of a Prisoner
December 2024 - Amey Community Limited
A company has been fined after it failed to manage the risk of legionella bacteria in the hot and cold water systems at HMP Lincoln.
The Health and Safety Executive (HSE) investigation followed the death of an inmate.
Amey Community Limited has now been fined £600,000 after pleading guilty to a health and safety offence.
Graham Butterworth died on 5 December 2017 after contracting Legionnaires’ disease while serving a prison sentence at HMP Lincoln.
Water samples from Mr Butterworth’s cell and nearby shower blocks tested positive for legionella days after the 71-year-old died.
Result - Death in 2017, Fined £600,000 in December 2024 plus costs of £15,000
Five infected with Legionnaires' via cooling towers
June 2023 - Riaar Plastics Limited
Plastics firm, Riaar Plastics Limited has been fined after five people became infected with life-threatening Legionnaires' disease from its water cooling towers.
The "extremely poor condition" of Riaar Plastics Limited's towers led to one person being admitted to intensive care in September 2020.
Principal Health and Safety Executive (HSE) inspector Jenny Skeldon said they were the worst she had encountered.
The West Bromwich firm pleaded guilty to health and safety breaches at Birmingham Magistrates' Court.
The poor condition of the towers at the firm's site at Black Lake allowed the bacteria to grow inside and in pipes, exposing employees and members of the public to risks of significant ill health, the HSE said.
Result - Outbreak in 2018, Fined £50,000 in 2023 plus costs of £11,000
Suspended sentences for bosses who ignored consultants' advice over Legionella risk
2010 - Isher Hangers Partners
Birmingham Magistrates' Court was told that, between June 2017 and February 2018, Kulwant Singh Chatha and partner Satpaul Kaur Chatha of Isher Hangers exposed employees of Isher Hangers, as well as members of the public, to Legionellosis at the site, which was situated in the vicinity of two local hospitals.
An investigation by the Health and Safety Executive (HSE) found concerns raised by their own water treatment consultants were ignored, and no Legionella risk assessments were in place.
"Isher Hangers was operating a cooling tower without biocide, ignoring the advice of their own consultants," said HSE inspector Karen Sweeney. "Cooling towers have the potential to spread bacteria that can cause serious illness or death, if not maintained in accordance with the published guidelines."
Result - Failings in 2009, Case in 2010. Each partner received a 12 weeks in prison, suspended for 12 months, and ordered to pay costs of £12,115 each.
Residents put at risk of deadly disease as company fined £900k
October 2024 - Sanctuary Housing
A company has been fined following an outbreak of legionella at its sheltered housing accommodation in Birkenhead, putting vulnerable residents at risk of contracting Legionnaires’ disease.
The deadly bacteria was detected at Vincent Naughton Court following the sampling of its water systems in the communal areas and flats in July and August 2018.
With all 44 samples testing positive for legionella, the residents were then evacuated from the Sanctuary Housing premises in August 2018, before returning in October and November 2018 after the water system was remedied through the installation of a chlorination unit.
A Health and Safety Executive (HSE) investigation found Sanctuary Housing poorly managed the risk of legionella in the water system of Vincent Naughton Court, with staff inadequately trained and supervised. The residents were a particularly vulnerable group due to their age and underlying health issues, putting them at a higher risk of contracting Legionnaires’ disease.
Result - Incident in 2017, Fined £900,000 in October 2024 plus costs of £11,500
Bupa fined £3m over care home resident’s Legionnaires' disease death
2018 - BUPA Care Homes
Bupa Care Homes failed to implement measures to control and monitor the hot and cold water systems at the Hutton Village Nursing Home in Brentwood during refurbishment works, Ipswich Crown Court was told.
In addition, it had failed to properly train staff responsible for overseeing legionella controls and measuring the temperature of the water.
Kenneth Ibbetson, 86, had moved into the care home in March 2015 but soon began complaining that he felt unwell. He died on 23 June 2015 in Basildon Hospital after contracting the disease, which is a waterborne form of pneumonia.
According to BBC News, samples taken from taps in Ibbetson's bathroom revealed there was a high concentration of legionella bacteria in the water.
Bupa Care Homes pleaded guilty to breaching s 3(1) of the Health and Safety at Work Act and was ordered to pay £151,482 costs.
Judge Emma Peters said "no one had a grip of the risk in Hutton Village care home" and the company had shown a "lack of remorse", BBC News reported.
Result - Death in 2015, Fined £3 Million in 2018 plus £151,500. (Fine reduced to £1.5 Million on appeal in 2019)
Four Seasons fined £600,000 over Legionnaires death
2016 - Kestrel Lodge (Four Seasons Healthcare)
Four Seasons Healthcare has been fined £600,000 for safety breaches after a 90-year-old care home resident died from Legionnaires disease.
John Bonser died at Kestrel Lodge on 15 November 2012 after contracting the disease, which is contracted through breathing in bacteria carried in water.
In making his ruling at Nottingham Crown Court, Judge Stuart Rafferty QC said that pressures in health and care funding were no excuse for the company failing to discharge its fundamental purpose of keeping residents safe over a significant period of time.
Prosecuting for Ashfield District Council, Bernard Thorogood told the Court that Mr Bonser became a resident at the home in August 2012. He was admitted to Kings Mill Hospital on October 29 2012 with Legionnaires disease.
Result - Death in 2012, Fined £600,000 in December 2016. Kestrel Lodge Closed in September 2016 following this case.