No Prosecution Over Legionnaire's Deaths
8 April 2015, 16:35
No-one will face prosecution in connection with the deaths of four people following a Legionnaires' disease outbreak in 2012.
Prosecutors investigating the Edinburgh outbreak - the largest in Scotland in a decade - say there is insufficient evidence to bring charges against any person or organisation.
They have not ruled out a Fatal Accident Inquiry, however, and a decision will be made following consultation with the families affected.
A Crown Office statement said that it had proved "impossible'' to identify the source of the Legionella bacteria which resulted in the death of three men and one woman between June 5 and July 15 2012.
A total of 92 cases were identified, with Bert Air, Sean Ferguson, John Lonnie and Sylvia Riddell dying after contracting the disease.
Gary Aitken, head of the health and safety division of the Crown Office and Procurator Fiscal Service (COPFS), 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.''
The Health and Safety Executive (HSE) said the investigation, which saw a team analyse samples from several sites, was one of the most complex it has ever undertaken.
The probe saw a number of companies reported for health and safety breaches unconnected to the outbreak.
It is understood a cluster of cooling towers in the south-west of the city formed part of the inquiry.
Legionella bacteria are commonly found in sources of water such as rivers and lakes.
They can end up in artificial water supplies such as air conditioning systems, water services and cooling towers.
Legionnaires' disease is contracted by breathing in small droplets of contaminated water. It is not contagious and cannot be spread directly from person to person.
The Crown Office said NHS Lothian, HSE and Edinburgh Council acted "quickly and effectively'' to curb the outbreak.
Alistair McNab, HSE head of operations in Scotland, 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 duty holders 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.''
Professor Alison McCallum, director of public health at 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 have shared our experiences with other public health teams.''
A Fatal Accident Inquiry is now crucial, according to law firm Irwin Mitchell who say they are representing 40 people affected by the outbreak.
Partner Elaine Russell said: "We have repeatedly called for more information to be shared with the victims but have been met with a wall of silence for years.
"It is embarrassing that they have had to wait so long for the authorities to investigate and share their findings. Three years ago four people lost their lives and almost 100 suffered from Legionnaires ' disease, yet the authorities are no closer to knowing what the source of the illness was.
"It raises the question of how we can learn lessons from this tragedy to prevent it happening again, especially as two smaller outbreaks also occurred in Scotland in 2013.
"The families affected want answers as to what caused such suffering across the city and we now believe that a Fatal Accident Inquiry is crucial in determining once and for all what happened back in 2012.''
Patrick McGuire from Thompsons Solicitors, also representing families affected, said: "This is very disappointing news from the Crown Office.
"This mass poisoning took place in our capital city and yet no one has been brought to book. What sort of message does that send out to the public and what does it say about how we stop any further outbreaks?
"My legal team will now begin immediate work on civil legal proceedings but the Crown Office must also convene a Fatal Accident Inquiry into the outbreak to provide answers for the victims and to stop this ever happening again.''