Terence Brooks

1. 1. inadequate interpretation of Legionella water sample results

   “Those who conducted the investigation and root cause analysis on the part of the hospital did not appreciate that notwithstanding the absence of the specific subgroup of Legionella serotype 1 in the water samples from the ward as compared to samples from the deceased that this was not conclusive as to the ward not being the source of the infection.”

2. 2. absence of outbreak investigation procedure

   “The hospital, although responding promptly to the infection, had no procedure in place detailing how the investigation of the cause of a legionella infection should be undertaken.”

3. 3. missing formal outbreak investigation protocol

   “The hospital should put in place an approved procedure for the investigation of any future outbreaks of Legionella infection should they occur. This procedure should describe and define clearly inter alia the nature, limitations and interpretation of the results of any microbiological testing undertaken.”

No published response was found on judiciary.uk.