Risks of not completing a Legionella Risk Assessment on time

by Water Hygiene Centre, on 19-10-2017
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It is a legal requirement to have a Legionellarisk assessment for water systems where there is a duty of care. If there is no risk assessment in place, the right time is now!

Once a Legionella risk assessment is in place, the revised ACoP L8 (2013) tells us to review it “regularly” in case any changes have occurred, or there is a reason to suspect the risk assessment is no longer valid.

Legionella Risk Assessment - what does the guidance say?

The HSE have removed the two year review frequency, to encourage us to keep our risk assessments relevant, up-to-date and proportional to the risks identified.

The British Standard publication BS 8580, defines what a Legionella risk assessment should include. It also states that the risk assessment should not be a “one-off exercise” and be a “live document”, this supports the ideals laid out in the ACoP L8. It prompts us to act in “anticipation of, rather than in response to changes”.


The Department of Health document HTM 04-01 tells us that “where new healthcare premises are planned or existing premises are to be altered or refurbished, the Water Safety Group [WSG] should be consulted at the earliest possible opportunity and risk assessments should be completed for all projects”.


So all relevant guidance documents are “singing from the same hymn sheet”, Legionella risk assessments should not only be in place, but reviewed regularly, treated as live documents and updated as required; ideally as soon as possible.

A simple way of identifying the need to update your risk assessment is to use the Water Hygiene Centre’s Legionella Risk Assessment Review Tool, which can clearly illustrate how up-to-date your risk assessments are, for each water system or building. 


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How soon should you complete your risk assessment?

By using a Risk Assessment Review Tool, it is easy to see when a change has occurred and therefore, when the risk assessment is no longer valid.

How soon should you complete your risk assessment?Whereas some criteria are easier to react timely to than others, such as a case of legionellosis, one certainly needs extra thought, what constitutes a “change in the water system”?

Although there is no guidance that states in black and white the answer to this question, perhaps a ward refurbishment or removing a cold water tank and pressurising the hot water system would constitute a significant change. In these examples, it is easy to pinpoint a time to act and review. Removal of a single wash basin is perhaps not a significant change, but when several small changes have occurred, maybe a balance is tipped towards a new risk assessment.

In each case, a question should be asked, are you going to learn anything? Will the risk change?

Best practice tells us to conduct the risk assessment in a timely fashion, or even better during the commissioning stage (as advised in HTM 04-01). The old adage “Get it right first time” is true here.

Trying to rectify mistakes or non-compliance with either the specification, or applicable standards after the building is brought back into use, can be a costly and highly disruptive exercise. This not only affects the water system but also the activity of that building or ward.

Examples of risks found during a risk assessment completed at the commissioning stage included:

  • Flexible hose connections fitted to wash basins behind IPS panels (See photo above);

  • Air handling units fitted with insufficient air gaps on drainage pipework and support struts obstructing the removable chiller tray;

  • Failure to install sufficient balancing valves on hot water systems with an adjustable flow-rate;

  • Absence of pipework insulation contrary to the design specification.

In each case, the findings were rectified by the contractor at their expense, before the new ward was opened, eliminating unnecessary risks. 


What difference does it?

As well as the examples above, the following risks have been identified when a Legionella risk assessment has not been updated;

  • Water Safety Plan2-white-bgAny new risk system identified or where a risk system has changed, the Water Safety Plan or Written Scheme will often need to be updated and a revised regime of checks and inspections applied. The risk is that insufficient or incorrect control measures could be applied leading to a loss of control and an unnecessary waste of time and other resources;

  • Where changes have occurred, have storage requirements been re-assessed? Any change in a water system may inadvertently increase risk of Legionella growth;

  • Where a change in use has occurred in a building, the ALARP target will have changed (see BS 8580). Therefore disproportionate control measures may be being applied. A general public building does not require the same control measures as a healthcare building, and vice-versa.

  • Use of an invalid risk assessment could lead to an HSE improvement notice. 


By undertaking regular reviews, it is easy to identify the right time to undertake a new Legionella Risk Assessment.

This will enable you to remain up-to-date and compliant, but also ensure the right control measures are in place in time and resource is not wasted.

We have also learnt that renewing risk assessments promptly after a change has occurred, can not only save money and disruption later on but more importantly eliminate any unnecessary Legionella risks at the earliest opportunity.


Further Reading: Read more about what is a legionella risk assessment, Mistakes to Avoid and Frequency >


Editors Note: The information provided in this blog is correct at date of original publication - October 2017. 

© Water Hygiene Centre 2019

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About the author

Water Hygiene Centre

The Water Hygiene Centre was established in 2009 to address the lack of independent water hygiene consultancy within the industry. From our humble beginnings, we have established ourselves as a market leader, helping clients identify and minimise the risk of waterborne contamination and disease, whilst improving compliance performance.

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