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Investigating Major Biological Agents Incidents

SPC/ENFORCEMENT/187

Version No:
1
OG Status:
Fully Open
Author Section:
HID
Issue Date:
29 February 2012
Review Date
30 August 2013
Target Audience
All HID SI 4 inspectors (and HID and FOD inspectors with sites undertaking high hazard biological agents work, in particular Containment Level (CL) 4 facilities)

Purpose

1. This SPC is primarily intended for Inspectors from HID SI 4 (Biological Agents Unit, BAU), although it is relevant to inspectors from FOD and HID CI who may provide the initial response to incidents and who have lead responsibility for the wider sites where the majority of high hazard, contained use biological facilities are located.  It should be read in conjunction with the regional FOD MIRP which gives practical guidance to inspectors responding to events that are, or may escalate into, major incidents.  This SPC complements the MIRP by providing additional help on specific issues that inspectors investigating biological agents incidents may come across.

Background

2. Each FOD region has a MIRP and HID has its divisional MIRP. All MIRPs are identical, except for the list of contact details, which are specific for every region or division. HSE procedures require that it is applied when an event occurs that requires HSE attention and meets the following criteria:

3. All FOD and HID operational staff are expected to follow their regional or divisional MIRP when responding to an incident that meets the above criteria.

4. This SPC augments the MIRP by providing inspectors with specific help regarding issues that they may not have come across before.  This reflects the unusual nature of biological agent incidents, for example:

Demarcation of responsibility between FOD and HID SI 4

5. HID SI 4 is responsible for enforcement of high hazard contained use biological agents work. These sites include all biological containment level (CL) 3 and 4 laboratories, as well as level 2 laboratories where biological agents are being propagated (typically, research laboratories). Clinical diagnostic CL 2 laboratories are the responsibility of FOD. The laboratories are always located within larger sites for which the HSE lead is FOD and, very occasionally, HID CI.

6. HID SI 4 sites are located across the country and the HID SI 4 inspectors are based in Bootle and Leeds. Therefore, liaison with colleagues in FOD and HID who are located closer to site will usually be necessary, as they may be best placed for any immediate site attendance.

7. HID SI 4 may also be approached to give technical advice and support regarding incidents and outbreaks involving biological agents other than those arising from contained use. In the case of Legionnaires’ disease, the HID SI 4 role is described in the Operational Circular (OC) 255/12. For other instances, the HID SI 4 Head of Unit (HoU) and intervention team managers will determine who is best able to carry out the work and whether attendance at site (or off site control) is needed.

8. During a Civil Contingencies event, HSE is a Category 2 responder. HID SI 4 may be asked for advice about, for example, a suspect package that arrives at one of the UK Reception and Screening Facilities. Where HID SI 4 is asked to help, the request is likely to be from the Home Office, the HPA or the Defence Science and Technology Laboratory. If HID SI 4 does provide help, we should ask to be kept abreast of further developments.

Interface with the MIRP

9. MIRPs contain common procedural information along with specific contact details, e.g. for HSE inspectors (both FOD and HID), council offices and emergency services within that region or division.  It defines a number of key roles within HSE major incident response, e.g. decision maker, incident controller, incident inspector.  It also contains guides, checklists and flowcharts which are designed to support the people who take on those roles during a major incident.  In Scotland, the MIRP contains an additional appendix reflecting the different Work Related Death Protocol procedures required.  The MIRP is regularly tested, reviewed and, if necessary, revised to ensure it remains fit for purpose.

10. It is recognised that the teams within SI 4 inspect over large geographical areas which may cover a number of FOD regions.  Rather than holding a copy of the MIRP for every region, SI 4 inspectors should have access to all of the regional FOD and HID plans. However, it would not be necessary for individual inspectors to have copies of all plans. HID SI 4 HoU and the intervention team managers will have hard copies of MIRPs for every FOD region and the HID divisional MIRP.  In the event of an incident occurring within normal working hours, further details to those included in the MIRP can be provided by The Redgrave Support Team (HID SI 4 management, inspectors and the BAU Support Team, BAUST). If the incident occurs outside normal working hours, please refer to paragraph 15. All MIRPs contain a list of out-of-hours numbers which may be useful to inspectors in any region.

11. The MIRP is maintained by administrative staff on behalf of the FOD Head of Division and updates are periodically sent to holders of hard copies.  Any SI 4 inspector who does not have access to the latest version of a regional MIRP should contact FOD administrators at their local office and request one.   An additional list of emergency contact details for all operational staff and managers in SI 4 is maintained by BAUST, and should be kept by the HoU and the intervention team managers. HID SI 4 inspectors should keep a hard copy of an updated contact details list for the intervention managers.  Other useful reference material for inspectors attending biological agent incidents is listed in Appendix 1.

Relevant legislation

12. Deliberate work with biological agents in the UK is underpinned by statutory notification, consent and regulatory systems that implement requirements of European directives and UK legislation. This is also subject to incident/accident notification. The main legislation is:

Notification of incident and initial arrangements

13  During office hours, HID SI 4 may be alerted to incidents either via other directorates or directly from the duty holder. If a member of the HID SI 4 unit takes a call alerting HSE to an incident that may meet the criteria, let the HoU or a HID SI 4 band 2 inspector know immediately.

14  The HoU and specialist band 2 inspector will then decide whether the incident warrants application of the MIRP. If this is the case, then they will:

15. If the incident occurs out of normal working hours, the HSE Duty Officer will contact either the HoU or band 2 specialist inspector, who will then determine whether immediate response is required and, if so, follow the procedure as above which may additionally require out of hours access to Redgrave Court or Leeds office (HID SI 4 inspectors based in Leeds should have contact details - numbers in the regional FOD MIRP - of band 1 in Leeds  available).

Note: Other than HSE role in providing advice as a Category 2 responder, HSE should not attend site for the purposes of immediate incident response and rescue.

Before attending site

16. If you are required to attend site, it should be on the basis of a clear understanding regarding your role, which may be:

17. Wherever possible, a minimum of two inspectors from SI 4 should attend together.  Inspectors should contact the site before attending to advise those in control to expect them and to ask them to ensure that, as far as possible, evidence is left undisturbed before HSE personnel arrive. However, given the nature of release scenarios, this may well be impractical or unsafe, and to do so may cause increased risk.

18. Ensure that you have up to date information as to the potential hazards at site (either provided by liaison with site or from site files), information as to the incident and situation – and that you are aware of the health and safety precautions required according to the HID SI 4 risk assessment.

19. Take your usual personal protective equipment (PPE) and information (provided by band 2 specialist and/or HoU) regarding any specific precautions (e.g. respiratory protection equipment, RPE).

20. Take investigation supplies (e.g. camera, notices forms, statement forms, evidence bags, etc). If the incident occurs out of hours and/or you do not have access to this material, the Redgrave support team will make arrangements for supplies to be delivered from the local HSE office as soon as practicable.

21. If initial information from the scene suggests a strong possibility that certain specialists will be needed, e.g. from the Health and Safety Laboratory (HSL) or specialist groups (SGs), it is advisable to contact them before attending site.  If they are aware of the incident at an early stage, they will be better able to respond quickly should their presence on site be needed.

Arriving on site

22. Whilst the emergency services are present, they have control of the scene and inspectors should take instructions from them.  Inspectors should introduce themselves to the senior fire, police and other relevant agencies officer on site and explain HSE role in investigating the incident.  It is useful to have a meeting to establish the current position and confirm whether there have been any casualties, together with the potential for release of hazardous materials and what arrangements are in place to mitigate this. Where fatality has occurred or the condition of infected people is such that fatality is foreseeable, agreement will need to be reached with the police regarding whether they retain control of the scene or hand it over to HSE once it has been made safe (see also paragraph 27).  Other key actions and considerations for inspectors during the early stages of the investigation are listed in Appendix 2.

23. Ensure that you are familiar with and follow any arrangements and procedures that have been agreed. This may include:

Controlling major incidents and liaison with the emergency services

24. HSE is a Category 2 responder under the Civil Contingencies Act 2004 and plays a supporting role in planning for and responding to emergencies.  HSE inspectors should resist any pressure to become involved in the incident command and control mechanism.  In the case of biological agents, HSE inspectors can assist front line responders by giving specialist advice on the agent and control measures (in accordance with our role as a Category 2 responder) or by promoting other agencies (e.g. HPA, see link to Memorandum of Understanding between the HSE and the HPA in Appendix 1) as a source of authoritative advice to decision makers at the scene (e.g. on decontamination).  

25. Inspectors should be prepared to give advice to the emergency services on health and safety issues within HSE remit.  However, the MIRP makes it clear that HSE staff should only intervene in their enforcement capacity in circumstances of extreme risk to the emergency services or others.

26. HSE does not have the resources of the police or fire service, and it may be necessary to rely on them in the short term for securing the site. The police in particular have an important role to play in site security and keeping people back.  If the investigation is likely to continue for more than a day, inspectors should request that the police provide overnight security.

27. Once the emergency services (or other relevant agency, e.g. HPA) declare that the site has been made safe, the mechanics of the handover to the investigators should be agreed with relevant officials.  Senior representatives of the various organisations on site should be reminded that no activity that may prejudice the investigation can be carried out without consulting HSE and gaining approval first.

28. Where inspectors are going to be working at the scene of an incident for more than a day, they should meet before work starts each morning for an opening briefing and hold a debrief meeting each evening.  This is to ensure that all HSE personnel are kept fully informed regarding developments on site and have the opportunity to flag up and discuss issues that arise as the investigation progresses (see also paragraph 37).

Action in the event of a fatality - the role of the police and manslaughter considerations

29. If death has occurred or is foreseeable, the police will have primacy for the investigation and control of the scene until they take a positive decision that no manslaughter offence has taken place.  HSE will assist with the manslaughter investigation whilst also investigating possible offences under the Health and Safety at Work etc Act 1974.  The exact working arrangements need to be agreed with the officer in charge in each case.  Further guidance is given in OC 165/10 and in the Work Related Deaths Protocol.

Site accommodation

30. Inspectors' powers enable them to require that accommodation is made available to them for use during an investigation. If this is not practical (e.g. due to risk of contamination), HSE can arrange for a Mobile Major Incident Room (MMIR) to be brought to site or can lease temporary office accommodation locally.  Further details and procedures for requesting the MMIR or temporary office accommodation are available in Section 4 of the regional MIRP.  Inspectors will need to consider the following in relation to the MMIR:

Entry into damaged buildings

31. Inspectors may face pressure from various parties to allow entry to damaged/evacuated buildings to enable investigations or remedial works to proceed after the emergency services have completed their work.  The overriding priority is to ensure that no-one is put at further risk, particularly members of the public.  It is therefore critical that inspectors do not act without first taking the appropriate specialist advice and do not feel that they must rush into making a decision.  Typical issues include:

32. HID SI 4 inspectors will be able to provide advice on integrity of containment measures before any work restarts at site.

Inspectors' health and safety

33. HSE has a corporate policy entitled 'Your health and safety' and a complementary 'Checklist for site risk assessment'.This states that an initial risk assessment should be conducted and all precautions identified by the risk assessment should be in place before work on site begins.  Inspectors should be familiar with the contents of these documents, and it is recommended that they keep hard copies with their MIRP for reference.

34. In addition, the SI 4 risk assessment provides specific advice in relation to biological agents.

35. A particular hazard which may not be obvious is the presence of asbestos at the scene.  Where there is reason to suspect the presence of asbestos, inspectors should not enter the site.  If in doubt, inspectors should seek specialist advice from SG Occupational Hygienists or FOD Construction Division Inspectors.

36. The guiding principles that inspectors should observe on site are:

37. Inspectors may feel obliged to work long hours and could find themselves in emotionally challenging situations in the course of the investigation.  It can be helpful to talk about these issues at daily briefing/debrief meetings.  HSE staff has access to a free counselling and support service provided by Right Corecare and a counsellor can attend site to talk to staff on request.  Where booking into local accommodation would reduce travel time and stress, this can be arranged via Expotel (contact details are provided in the MIRP).

Night working

38. The person in charge of the response may request the HID SI 4 inspector to work through the night.  Such requests should be treated sympathetically as there will be pressure to re-open roads, allow the public back into their homes, etc.  There are two considerations:

  1. can the work be done safely at night? and
  2. are technical staff (e.g. from HSL and SGs) content to remain on site to supervise the activities of the response team and ensure that no evidence is disturbed?
    If the answer to both of these questions is yes, then night working may be allowed.  The police may be able to help by maintaining a cordon overnight. LAs also have a role in security of the site perimeter and may be able to assist.

How the investigation is carried out

39. Appendix 3 contains an evidence checklist which covers the key evidential issues facing inspectors investigating biological agent incidents.

40. It may be necessary to request input from specialist inspectors (e.g. Control & Instrumentation, Process Safety) or the HSL. In either case, clear terms of reference and roles should be agreed. Inspectors should remember that HSL staff do not have the same level of legal/investigative training as inspectors, and will require supervision to ensure compliance with the Criminal Procedures and Investigation Act 1996 and preservation of the chain of evidence.

Handling the media and communications

41. Disease outbreaks and biological agents releases are always newsworthy events and investigating inspectors are likely to encounter personnel from the media.  HSE has a policy of openness and transparency in its dealings with the media.  Press Office should be contacted at an early stage because they can deal with many media enquiries and, in doing so, take the pressure off the inspectors at the scene.  The senior HSE manager involved in the investigation should normally give any press briefings; however, inspectors on site may be requested to comment and should be prepared to make a brief holding statement as set out in the MIRP.

42. Although it is clearly inappropriate to offer detailed comments in some circumstances, for example where it may prejudice criminal proceedings, inspectors can respond to enquiries from the media helpfully by giving information such as:

43. HSE Secretariat need to be informed within one hour if there has been a potential major incident.  Contact with Secretariat will be via the Incident Controller (in office hours) or the duty press officer (out-of-hours), so it is important to provide a briefing to these people at an early stage of the investigation which gives them a meaningful appraisal of the situation.

44. The police and LA may all have press officers on site.  HSE inspectors should liaise with them as appropriate, e.g. to ensure messages concerning public safety are consistent.  They may also provide a useful conduit for delivering common messages, and can help by managing local press and TV reporters where there are no Government News Network representatives available.

Dealing with bereaved relatives

45. In 2006, HSE introduced 'Working with victims: HSE policy statement' in response to concerns that existing arrangements fell short of public expectations.  Inspectors should refer to this policy statement and the guidance set out in Contact with relatives of people killed through work activities, which sets out a timetable for making initial contact with the bereaved family, subsequent meetings and supply of information.

46. HSE will not be the only organisation wanting to talk to the bereaved family.  The police will make contact with them and may appoint a Family Liaison Officer (FLO).  Coroner's officers may also have early involvement with the family.  Regardless of whether the police have primacy and/or appoint an FLO, inspectors should still follow Contact with relatives of people killed through work activities and offer to meet with the family.  The police should be kept informed of HSE contact with the bereaved.  Where an FLO is appointed, communication arrangements should be agreed with them to ensure that there is no scope for confusion or inconsistency.

Further information

47. For further information contact the Biological Agents Unit, HID SI 4.

Appendix 1- Useful reference material for inspectors responding to major biological agents incidents

It is recommended that, in addition to the MIRP and this SPC, inspectors in HID SI 4 keep hard copies of the following documents in a convenient location for taking to site in the event that they respond to a major incident:

Emergency contact list for HID SI 4

Work-Related Deaths Protocol

Contact with relatives of people killed through work activities

OC 165/10 'Work Related Deaths: liaison with police, prosecuting authorities, local authorities, and other interested authorities including consideration of individual and corporate manslaughter / homicide

HSE intranet page - Your health and safety, in particular the 'Checklist for site risk assessment'

HID SI 4 risk assessment

Operational Guidance: Material and evidence management (collection, retention and disposal)

Memorandum of Understanding between the HSE and the HPA.

Appendix 2 - Key information/action checklist on arrival at the scene

This is not an exhaustive or priorities list, but it is intended to be a useful aide memoire of key actions for inspectors to take and information to gather on arrival at the scene of a major incident involving biological agents:

Appendix 3 - Biological Agents Incident Investigation – Evidence preservation Aide Memoire Information to consider immediately prior to visiting site of incident

At this time, inspector(s) assigned to attend major incident sites where accidental releases of biological agent(s) may have occurred should gather relevant information from various sources (including the duty holders) to build an informed picture of both the potential routes of accidental release of the pathogen(s) and potential risks to human health and/or the environment that the incident may have posed and is likely to pose.

Evidence to gather on site

The range and type of evidence to be gathered is likely to be highly dependent on the site, the biological agent concerned, and the nature of the incident. The lists below are not exhaustive, but they aim at providing an indication of the types of material to be gathered as evidence and information that may be relevant for an investigation of a major incident involving biological agents.

Initial assessment as to the level of support necessary, including the type and range of specialisms that will need to participate in the investigation.

Documentary evidence

Physical evidence

Due to the uncertainties surrounding the risks to human health and/or the environment from accidentally released biological agents, the amount of actual physical evidence that could be gathered from a major incident involving biological agents may be limited. In such scenario, visual examination supported by relevant photographic and/or video evidence may be crucial to support various lines of enquiries. HSL may be able to provide some technical support for evidential issues involving biological agents.

Isolators and Microbiological Safety Cabinets - condition and integrity
Air handling system – instrumentation, controls and process safety systems
Disinfection (including fumigation) procedures

Containment space physical integrity (i.e. its sealability where fumigations take place)

Entry/exit arrangements and procedures
Any other relevant containment measure(s) included in Schedule 3 Parts II-III of the Control of Substances Hazardous to Health 2002 Regulations, in Part II of Schedule 8 of the Genetically Modified Organisms (Contained Use) Regulations 2000, and in the Specified Animal Pathogen Order 2008 licence conditions, as appropriate and where relevant.

    Drainage system – condition, maintenance and containment status
Effluent treatment plant and process – condition, maintenance and containment
Instrumentation and process control – arrangements adequacy
Transport arrangements - adequacy for waste disposal transport between laboratory and autoclave/effluent treatment plant

    Inventory - adequacy
Storage and storage areas – suitability and adequacy
Transport of biological agents from storage to the laboratory

Work environment and patterns
Work load and stress issues
Health and safety culture

Preservation of evidence

Updated 2015-03-31