Trust fined after employees are exposed to TB bacteria

Date:

17 January 2013

Release No:

LSE/010/13

Royal Brompton and Harefield NHS Foundation Trust has been fined for safety failings after employees were exposed to a potentially deadly strain of multi-drug resistant tuberculosis (TB) bacteria when a test vial smashed in a specialist laboratory.

The incident at Royal Brompton Hospital on 17 January 2011 was investigated by the Health and Safety Executive (HSE), which identified numerous issues with the management and maintenance of the CL3 containment facility that is used to provide a microbiological diagnostic service.

They included:

• Inadequate risk assessments for activities involving TB, and consequently no safe system of work
• Critical control measures, including the laboratory sealability and laboratory filters, weren't examined, monitored, tested or maintained
• A lack of understanding about what constituted a critical control measure
• Poor emergency arrangements in the event of an incident, with staff unaware of what they should do
• Those responsible for health and safety in the laboratory were lacking appropriate training

Westminster Magistrates' Court heard yesterday (16 January) that the test vial containing a strain of multi-resistant TB bacteria smashed when it fell to the floor while being handled.

Three employees were present at the time. A fourth also risked exposure when she helped with the clean up operation the following day.

No-one suffered any adverse effects, but HSE established that Royal Brompton and Harefield NHS Trust (RBHT) should have developed and implemented a safe system of work to prevent such an incident. The Trust should also have better implemented appropriate and adequate control measures, and ensured that staff were suitably trained.

Magistrates were told that HSE had earlier issued an enforcement notice for the same laboratory facility in 2002 for failing to ensure it was sealable for disinfection. The then defects were rectified, but were allowed to reoccur over time.

RBHT, of Sydney Street, London, SW3, was fined £12,500 and ordered to pay £25,000 in costs after pleading guilty to breaching Section 2(1) of the Health and Safety at Work etc Act 1974.

After the hearing HSE Inspector Mara Ajder said:

"Multi-drug resistant TB is a potentially deadly bacterium. There are well established practices for handling this agent safely, but in this case these practices simply weren't met and several members of staff were exposed to a real risk of infection.

"The consequences of that one smashed vial could have been very serious, and the incident highlighted some serious flaws with controls and ways of working within the containment laboratory - a facility where the highest possible standards are necessary at all times.

"Royal Brompton and Harefield NHS Trust failed in its duty to ensure the health, safety and welfare at work of its employees in its management of health and safety in the laboratory."

Notes to editors

1. The Health and Safety Executive is Britain's national regulator for workplace health and safety. It aims to reduce work-related death, injury and ill health. It does so through research, information and advice; promoting training; new or revised regulations and codes of practice; and working with local authority partners by inspection, investigation and enforcement. www.hse.gov.uk
2. Section 2(1) of the Health and Safety at Work etc Act 1974 states: "It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees."

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