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Care home slated by family over 'horrifying' legionnaires death

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Andy Clegg with his sister Joanne Denyer
Andy Clegg with his sister Joanne Denyer

A WOMAN has described the “horrifying” experience of watching her brother die from legionnaires’ disease he contracted while living at a New Forest care home.

Joanne Denyer emotionally recalled the awful suffering 56-year-old Andy Clegg went through before dying in hospital and how it had fuelled their fight to get justice.

“In the hospital he was calling out ‘help me’, ‘help me’,” she told the A&T. “When he was not fully sedated and in intensive care it was so undignified.

“He suffered stress, anxiety, discomfort and agitation and he could not drink, sleep, breathe or remain still. It was just… horrifying.”

Last week an inquest jury ruled Andy’s death was accidental but due to legionnaires’ disease. It heard how Andy was vulnerable because of corticobasilar degeneration and was at Fordingbridge Care Home as he had mental health difficulties.

It was told there were long runs of hot and cold water pipes in close parallel proximity at the Station Road home, creating a potential for heat exchange. Over a period of time legionella bacteria colonised parts of the water system and Mr Clegg was fatally infected.

Doctors diagnosed Andy with legionella pneumonia, a complication arising from the legionella bacteria, when he was admitted to Salisbury General Hospital.

He was placed on a ventilator in intensive care in late October 2017 and transferred to a ward on 3rd November. He had respiratory difficulties and died two days later.

The inquest revealed investigations are ongoing into Sentinel Healthcare, which runs the Fordingbridge Care Home, among others in the New Forest.

Coroner Nicholas Rheinberg urged national watchdog the Care Quality Commission (CQC) to improve the training it gives inspectors to spot the fatal bacteria.

He has sent a Regulation 28 notice to both the CQC and the Royal Institute of British Architects (RIBA) warning both organisations to outline within 56 days what action they are taking to help prevent future deaths.

Evidence at the inquest, the coroner added, revealed architects designing healthcare premises “rarely” took into account water safety considerations, while care home inspectors had “lacked training” to help them identify risks associated with legionella.

Released to the A&T after making a special request, the notice said Fordingbridge Care Home had been “constructed with little attention to water safety”.

Joanne said the family had been “shocked” by the way Sentinel handled the situation. She explained it did not contact her or younger brother, Matt Clegg, when Andy was first admitted to hospital.

“It is beyond belief, it really is,” she said. “My brother used to go and see Andy every Thursday, but when he went round that time he went upstairs and knocked on his door but found it was locked.

“He then went and asked a staff member and they said to see the manager. It turned out Andy had been admitted to hospital on Monday and they had not contacted us.”

Joanne (55) and Matt (48) had suffered 16 months of agony since Andy’s death which had not been helped by Sentinel’s actions, she said.

The company had not readily acknowledged problems at the home and made life “difficult” for their lawyers, Irwin Mitchell, prior to the inquest, she claimed.

“We entrusted Sentinel to look after Andy but our family find it difficult not to think we were let down with terrible consequences,” she added.

“All we can hope for now is that his death was not totally in vain and reinforces how dangerous legionnaires’ can be. It is vital that businesses and public bodies ensure they take all necessary steps to prevent others contracting the disease.”

Jatinder Paul, from Irwin Mitchell, said: “This tragic case vividly highlights the devastating consequences of legionnaires’ disease.

“Andy’s death has had a profound effect on all of his family and for the last 16 months they have had a number of concerns which have been ignored by Sentinel until the inquest, when they have finally accepted that Andy contracted Legionnaires’ disease at the Fordingbridge Care Home and this ultimately caused his untimely death.

“Whilst nothing can ever make up for Andy’s death we are pleased that the hearing has helped answer the family’s concerns, and we are pleased the coroner will now write to the CQC to raise his concerns that more needs to be done for the training of inspectors in water safety to prevent future deaths from legionnaires’ disease in the care setting.

“We hope that the coroner’s concerns have far reaching implications in terms of improving safety for care home residents, some of whom are extremely vulnerable people.”

He said investigations into Sentinel and the care home had been launched by the CQC, Public Health England and Hampshire County Council, and it is understood civil action could follow.

The CQC website states the last inspection of the home in May 2017 rated it ‘good’.

Asked to comment, a Sentinel spokesman told the A&T: “The company participated in the [inquest] proceedings and, having heard the evidence, the jury returned a conclusion of accidental death.

“The company would like to take this opportunity to once again express their sincere condolences to the family for their sad loss of their family member Andrew Clegg.”

Alison Murray, CQC’s head of inspection for adult social care, said it first became aware of the Andy’s illnesses via the Health and Safety Executive after he was admitted to hospital.

“Our actions at the time of Mr Clegg’s death were to ensure the provider took action immediately to manage the risk with the water supply following guidance by Public Health England,” she said.

“CQC are in the process of acquiring further information and will then consider what future enforcement or legal action we will want to take.

“We have received the coroner’s letter and this is something we do take very seriously. CQC will discuss the recommendations and respond to the coroner in due course.”

She added: “We believe that people using the service are entitled to receive safe, effective and high-quality care that meets their needs. Our priority will always be the safety of people using health and social care services.”

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