To review how the outbreak of legionnaires disease in Hereford City was managed.

The Committee began its review of how the outbreak of legionnaires disease in Hereford City in October 2004 had been managed.

 

The following people had been invited to provide information to the Committee:

 

·         Dr Mike Deakin                         Director of Public Health – Herefordshire

·         Dr David Kirrage Health Protection Agency - Hereford and Worcester Local Health Protection Unit

·         Mrs Lynne Kedward Hereford Hospitals NHS Trust - Acting Director of Nursing at the time of the outbreak and now Project Director – Emergency Services Redesign

·         Mr Paul Nicholas Herefordshire Council - Environmental Health Manager (Commercial)

·         Mr Andrew Tector Herefordshire Council - Head of Environmental Health and Trading Standards

 

Each invitee had provided a written submission in advance, which had been circulated, to Members of the Committee.

 

The Committee had also received a letter from Mr Paul Bates, the Chief Executive of the Herefordshire Primary Care Trust, reflecting on his personal experience as a Chief Executive tackling his first major public health challenge.

 

Dr Ian Tait General Practitioner and Chairman of the Primary Care Trust’s Professional Executive Committee had also written about the communication of information to GPs during the outbreak.

 

Mr Neil Pringle, Chief Executive of Herefordshire Council, was also present to advise the Committee and comment on his own involvement in managing the outbreak.

 

Ms Ann Fleming, recently appointed Communications Manager for the West Midlands Region of the Health Protection Agency was also present.

 

The Chairman explained that the Committee’s intention in conducting its review was to focus on the logistics of the outbreak, the lessons learned, and to establish the readiness to deal with a similar or potentially more serious event in the future.

 

Statement by Dr Kirrage

 

Dr Kirrage gave a presentation on the chronology of the outbreak broken down into five stages: identification and investigation of first confirmed cases; formation of the Outbreak Control Team; the restructuring of the Outbreak Control Team; the running of the investigation; and the debriefing after the outbreak was over.  He identified lessons learned at each stage and the outcomes and key messages.

 

The lessons learned included:

 

·         Outbreaks can become big very quickly and result in extensive media coverage.

·         Demand for media coverage will impede the investigation unless media support is available.

·         Such situations will generate a high level of political interest.

·         The respective responsibilities of the Health Protection Agency and the Primary Care Trust had initially been uncertain although this had been very quickly resolved.

·         There had been issues about protecting patient confidentiality particularly from the national press.

·         The separation of the strategic management of the incident from the investigation and management of the outbreak had worked well.

·         Experienced media support was essential.

·         The economic impact could influence the respective responses of the Local Authority and the Primary Care Trust.

·         There had been very good working relationships within the Outbreak Control Team.

·         The investigation could be left to the outbreak control team but there was a need to be aware of the effect on other Primary Care Trust Staff and keep them fully up to date.

·         There had been some contrary expert advice.  It had been expected that employees where the source was located would have been affected but this had not proved to be the case.

·         Good resources had been available both at national level and locally where there had been excellent support from an extremely able Environmental Health Team.  The use of the GIS software package to map the outbreak had been very helpful.

 

The outcomes included the use of new techniques and agencies; new information about Legionnaires disease; the preparation by the Health Protection Agency of new Legionnaires disease guidance; and the introduction of Health Protection Agency regional press officers.  Root Cause Analysis methodology had been used to identify and explore strengths and weaknesses in managing the outbreak and establish best practice that could be applied to other outbreaks.  Dr Kirrage noted that the Chief Medical Officer had been supportive of the findings and had approved a plan for their dissemination.  This included a national conference in September 2004.  Dr Kirrage believed that the lessons learned would prove beneficial in managing any future incidents of this nature.

 

He concluded that the key messages were:

·         The need for awareness of the scale of an outbreak and the effect on the Primary Care Trust in providing local health services.

·         An experienced media response was vital.

·         The strategic management of the incident should be separated from the investigation and management of the outbreak.

·         The need for dedicated, large rooms to accommodate the Outbreak Control Team, noting that Environmental Health Staff had had to travel across the City to attend meetings.

·         It had been fortunate that there had been very good working relationships between the participant organisations.

 

Statement by Dr Deakin

Dr Deakin gave a view on the outbreak from his perspective and that of the Primary Care Trust.  He agreed with Dr Kirrage’s comment that there had been initial uncertainty about the respective roles of the Primary Care Trust and the Health Protection Agency.  However, this had soon been clarified.

 

He explained that it is often difficult to be sure that an outbreak is occurring because the number of cases often increases slowly and incrementally.  In the event, the Health Protection Agency and Primary Care Trust had acted quickly after the first two cases.  However, every situation was different and a judgment had to be made as to when it was necessary to call in the additional resources required to manage an outbreak.

 

Communication had been vital.  He thought that the Primary Care Trust could possibly have done more to ensure that its staff were kept up to date.  In terms of the wider population the media had proved helpful in raising awareness.  It had been important to be honest and maintain public confidence.  As the incident had progressed it had become apparent that the Primary Care Trust’s focus on infection control had to be balanced against the broader responsibilities of Herefordshire Council, which had had to be mindful of issues such as the economic impact on Hereford City.

 

It was noted that the practicalities of testing for the disease had given the impression of some uncertainty in responses to the public and the media.  Dr Kirrage and Dr Deakin explained how an initial test could show infection was present but to determine the precise strain of infection could take a further 10-14 days.

 

Statement by Mr Tector

 

Mr Tector commented on the role played by Environmental Health Services.  He explained the legislation, which defined the responsibilities of the Environmental Health Service and drew attention to the role of the Health and Safety Executive (HSE).  He noted that because of their responsibilities, including determining whether criminal charges should be brought, the HSE had carried out far more detailed investigations to determine whether there had been compliance with the relevant Codes.

 

He explained how the epidemiological expertise of Environmental Health Officers had helped them in obtaining case histories and other relevant details.

 

He also reported on the establishment of a helpdesk to answer questions from business and the public and, in the absence of media expertise in other agencies, on the beneficial role played by the Council’s Public Relations Unit, which had allowed the service to focus on the outbreak. 

 

He believed that the work with IT services to use the GIS system to map the outbreak had reduced the time taken to identify the source. 

 

He highlighted that one of his concerns about managing a similar situation in the future was the legislative changes, which would remove enforcement powers from the Local Authority and transfer them to the Environment Agency.  He did not think that staff at the Agency would have the same breadth of epidemiological skills and would certainly lack local knowledge.  This needed to be addressed at national level.

 

 

Mr Nicholas then gave a presentation demonstrating how the GIS system had been used to map the outbreak.

 

Statement by Mrs Kedward

 

Mrs Kedward commented on the role played by the Hereford Hospitals NHS Trust.  She explained that it had been important to clarify roles from the outset and the Hospitals Trust had been clear that its role was to treat patients and liaise closely with the other agencies involved in the outbreak.  The hospital had also co-ordinated all the specimens.  Staff had been kept fully informed and reassured that there was no danger of infection from patients.  Nursing staff had been involved in establishing patients histories to assist with the investigation.

 

There had been some difficulties with the national press trying inappropriately to obtain details of patients.  The Trust had sought to ensure that all enquiries were dealt with by the main enquiries line.

 

A small team had been formed dedicated to working on the outbreak and due to the time spent on the outbreak by the team there was an issue as to how the situation would have been managed if the outbreak had continued over a prolonged period.  A second team would have needed to be involved.

 

In terms of capacity the Trust had liaised with the wider Health Network over whether additional capacity was needed.  Plans were in place to free up capacity in terms of major incidents but in this instance the cases had increased incrementally.  There had been very good communications and working relationships with GPs.   This had ensured that no one was sent for admission to hospital unless absolutely necessary.

 

Statement by Mr Pringle

 

Mr Pringle commented that overall the consensus was that the outbreak had essentially been well handled.  What needed to be considered was how much this was due to good management and how much to good fortune and whether improvements could be made. 

 

He thought consideration could be given to whether formation of the Gold Team to oversee the strategic management of the incident had been early enough; whether the Council had remained part of the Gold team for too long; and whether there was a point at which more positive messages could have been given to the public about going into the City centre.  On balance he thought that it might have been possible for the view to be taken that the outbreak was over and for the Council to start giving more positive messages 24 –48 hours sooner than it had done.  It was, however, a matter of fine judgment.

 

In terms of good fortune there had been tremendous co-operation from Bulmers who had voluntarily closed the cooling tower suspected of being, but not at that time proven to be, the source of the infection.  Had the Council instead been forced to use its powers to order closure at that stage and the suspicion proved mistaken the Council could have faced a significant bill for compensation.

 

The resources available to the Authority as a unitary authority, the co-terminosity with the Primary Care Trust and the Hospitals Trust and the good working relationships had been of huge benefit in responding to the outbreak.

 

The outbreak had been relatively short but he had observed staff becoming tired.  In future he thought the Primary Care Trust and the Authority would need to be mindful of the need to ensure that committed staff were rested.

 

A further point, which was quickly accepted, was that at every stage decisions and the reasons for them, including the evidence available at the time should be recorded.  This would be good practice in any such situation.

 

Other Comments

 

In response to a comment about the importance of communications, Dr Deakin explained the approach taken to press releases.  He confirmed that if there had been nothing further to report a press release had been given to that effect.  It was acknowledged that a difficulty had arisen following the issue of a release on the first Friday of the outbreak.  Although arrangements had been made for any follow up enquiries to be dealt with by a national hotline it had broken down.  This had not been discovered until the following Monday.

 

Mr Tanner, of the Hereford Times, was present at the meeting and the Chairman invited his views from a media perspective.  Mr Tanner commented that it was important that one agency took overall control and that should be the Health Protection Agency.  It was important that teams on the ground were not distracted.  In terms of dealing with the enquiries from the national press it was important that staff were briefed on the appropriate way to respond.

 

The Committee adjourned at this point. 

 

Questions

 

When the Committee reconvened, a question and answer session was held and the principal points raised are summarised below.

 

·         Clarification was sought on the action taken following the identification of symptoms of legionnaires disease in a man on 8th October, as referred to in Dr Deakin’s written submission

 

      Dr Deakin explained that symptoms of legionnaires disease were similar to the symptoms of other diseases, particularly types of pneumonia.  No one had identified at that stage that the patient had in fact contracted legionnaires disease.  The cases as a whole varied in severity and hospital treatment was not automatically necessary.  It was thought possible that not all cases during the outbreak had been identified. 

 

·         It was explained that, whilst the full emergency planning group had not needed to be convened, it had been decided to mirror the established system and Gold and Silver commands had been established accordingly.

 

·         That the approach to dealing with the media had been both proactive and reactive, with all parties signing up to the press releases.  Care had been taken to emphasise where appropriate and there was uncertainty, for example while test results were awaited, that the authorities were acting on the basis of probabilities.  The caution which needed to be exercised had been demonstrated by the incident where, after it was believed the outbreak was over, a further case had been reported.  It was established that this was because of delay in reporting and identifying the symptoms and the outbreak was indeed over.  However, an inaccurate report had appeared in the media creating public concern that the outbreak was not over.

 

·         It was asked whether, given the serious economic effects, consideration had been given to issuing more positive press releases.  Dr Deakin advised that he had emphasised throughout that, following all the checks, Hereford was the safest place in England, but this was not what the public had wanted to hear.

 

·         In terms of the threshold for declaring an emergency Dr Deakin explained that there were plans in place for a flu epidemic or something of that nature.  The difficulty with something like the legionnaires disease outbreak was that the picture had emerged slowly.  In those circumstances experience and judgment had to determine the level of response.

 

·         The contribution strong personal relationships had made to managing the outbreak had been highlighted in the statements made to the Committee.  A Member suggested that there was perhaps a case for formalising these relationships, particularly as it was when people were under stress and tired that there was the potential for such relationships to become strained.

 

·         It was asked whether there should be any changes in the boundaries of responsibilities in the light of experience.  Dr Kirrage commented that prior to the establishment of the Health Protection Agency the Consultant in Communicable Disease Control in Hereford had been part time.  More cover was now provided through the Local Health Protection Unit.  When the outbreak was declared three people had been transferred from Worcester to Hereford.  The new arrangements had delivered a better local response than would previously have been the case.  There had also been a greater ability to call on national resources, such as those at Porton Down.  It was, however, important to retain local knowledge.  In gathering evidence benefit had been derived from staff from the Agency being paired with local Environmental HeaIth Officers. In conclusion, as he had previously mentioned, whilst there had been some initial tentativeness the respective roles had been quickly established.  He noted that the appointment of Regional Press Officers had been a direct result of the outbreak.

 

·         Mr Tector agreed with Dr Kirrage’s comments on the importance of local knowledge and also the local links with the Health and Safety Executive and the Health Protection Agency.

 

·         Mr Tector acknowledged that whilst wet cooling systems had to be registered this did rely on the Council being kept informed and it was difficult to ensure that the register was up to date.   In general firms did notify the Council that they had such systems.  It was more common for firms who had decommissioned wet cooling systems to fail to notify the Council so that they could be deleted from the register.  In addition there were a number of other potential sources, which did not have to be registered such as meat humidifiers.  As a consequence of the outbreak the Council did now have an improved database, which would save time in the event of another outbreak.

 

·         Mr Nicholas was informed the Committee that as part of the ISO9001 accreditation, the Service was producing procedures that relate to most activities undertaken.  A procedure to deal with single cases and outbreaks would be written and would form part of the Quality Management System.

 

·         Mr Tector reiterated his concern that the transfer of powers from the Environmental Health Service to the Environment Agency had the potential to hamper the effectiveness of the response to certain incidents.  Mr Pringle added that there was currently an overlap of powers in certain areas and the Environment Agency might feel that this hampered its operations.  However, in his view a Local Authority was better placed to determine local priorities than a national agency.  Herefordshire as a unitary authority had the capacity to exercise the relevant powers and meet its responsibilities.  Dr Kirrage noted that the resources of the Environment Agency could easily be stretched and local expertise could make an important contribution.

 

·         In response to a question about the capacity to deal with a greater emergency Mrs Kedward explained that Major Incident Plans were in place and there were a number of ways in which additional beds could be made available, including making use of capacity within the NHS as a whole.  The Plans were being reviewed, given changes to the hospital, and made more user friendly.  

 

·         In answer to a question about how the recommendations in his report were to be taken forward Mr Nicholas advised that the Major Incident Plan was owned by the Primary Care Trust and the Strategic Health Authority and reviewing it would be their responsibility.  Work was planned with the Health Protection Agency to develop a bespoke operational plan for dealing with Legionnaires disease.  The question of representations to the Government about the transfer of powers to the Environment Agency and making Legionnaires Disease a notifiable disease had yet to be addressed by the Council.  Officers would be carrying out further work in response to the agreed lessons learned.

 

·         It was requested that further information be provided to the Committee on the implications of the removal of certain powers from the Environmental Health Service and their transfer to the Environment Agency; what early warning systems were in place or could be put in place to assist in dealing with outbreaks such as the legionnaires disease; and an indication given of the one thing in particular those making statements to the Committee would have done differently.

 

 

On behalf of the Committee the Chairman thanked everyone for their attendance and the information they had provided to the Committee.

 

 

The Committee adjourned between 11.20 and 11.40.