'No Prosecutions' Over Legionnaires' Deaths
The Crown Office says no company or organisation will be prosecuted over the deaths of four people from Legionnaires' Disease in Edinburgh.
But a number of firms will face court over health and safety breaches.
The report issued relates to an outbreak of Legionnaire's in west Edinburgh where four people were killed between 5 June and 15 July 2012.
An investigation by the Health and Safety Executive and Lothian and Borders Police into the circumstances of the deaths began immediately under the direction of the specialist Health and Safety Division of the Crown Office and Procurator Fiscal Service.
The Crown Office say, despite the best efforts of the scientists, it has proved impossible to identify the source of the Legionella bacteria which resulted in the death of four people.
As a result Crown Counsel has concluded that there is insufficient evidence to prosecute any person or organisation for the deaths.
The investigation did throw up some potential health and safety breaches - and a number of organisations face prosecution. A decision on whether to hold a fatal accident inquiry is still to be made. This decision will be made following consultation with the families.
Gary Aitken, Head of the Health and Safety Division of the Crown Office and Procurator Fiscal Service said; “Following a complex and thorough investigation which involved detailed genetic analysis we can only conclude that there is no scientific basis for any prosecution related to the deaths and as a result no criminal proceedings are instructed by Crown Counsel.
“This was always going to be a difficult and complex investigation due to the number of potential sources in the Gorgie area but we continued on in the hope that the necessary scientific evidence would come to light. Unfortunately that hasn’t happened.
“We will now consult further with the families before making any decision in relation to a Fatal Accident Inquiry.”
Professor Alison McCallum, Director of Public Health and Health Policy, NHS Lothian, said; “I would like to once again express my sincere condolences and sympathies to the families of those who died during this outbreak and the patients who were affected by Legionella.
“The actions taken by the Incident Management Team at the time of the outbreak minimised the impact on public health. However, as is often the case in outbreaks of this nature, the further microbiological, environmental and genetic investigations have been unable to definitively establish the specific source.
“The review of outbreak management and the subsequent public health research has proved valuable in enhancing the existing knowledge on Legionella outbreaks and control and we shared our experiences with other public health teams. On behalf of the Incident Management Team I would like those who contributed to this research and the multi-agency team for their efforts.”
HSE Head of Operations in Scotland, Alistair McNab said; “This was the largest outbreak in Scotland in the last ten years and one of the most complex HSE has investigated, involving visits to multiple sites and dutyholders including contractors and sub-contractors to check compliance with legionella control standards.
“As HSE and public health experts made clear at the time of the outbreak the source may never be conclusively identified, based on our experience from previous outbreaks. Two smaller outbreaks occurred within Scotland during 2013 and again, despite extensive and thorough investigation, the sources could not be proved.
“This can be due to the fact that Legionnaires' disease can have a long incubation period of up to 19 days, so by the time an outbreak is notified to HSE and other regulatory bodies and sampling carried out on water systems, the bacteria levels may have changed or the source producing bacteria may have ceased operation. In addition, as a precautionary measure to prevent further ill health when an outbreak is declared, companies are encouraged to shock-dose their cooling towers with chemicals, which again can prevent positively identifying the source."