Royal Hospital for Children and Young People and Department of Clinical Neurosciences: response to the review of water, ventilation, drainage and plumbing systems

NHS Lothian's response to actions identified in NHS National Services Scotland's review of water, ventilation, drainage and plumbing systems in the Royal Hospital for Children and Young People and Department of Neurosciences, Edinburgh.


NSS Review: Independent testing identified no widespread contamination of the water systems, however, remedial action is required on a number of water system areas as well as system wide disinfection prior to occupation.

NHS Lothian response: Remedial actions are underway and will be complete prior to occupation. Changes to the regime to maintain water quality have been made to address the findings of this review. System-wide disinfection will take place in the required timeframe prior to occupation.

Issue NSS Review NSS Action Assessment NHS Lothian action
Water services augmented care Pseudomonas found in taps, in Paediatric Medical Inpatients and DCN Inpatients . (SHTM 04-01 Part A published in July 2014) All taps (not just TMT/TMV4) to be disinfected and retested. Inspect and replace, as appropriate, taps, tap components and pipework. Replace tap strainers and cartridges in affected TMT taps. AGREED
All taps found positive for pseudomonas prior to occupation will be disinfected and retested using an agreed method statement. To be completed by the end of September 2019.
Water services non-augmented care Swarf and biofilm found in tap strainers, contrary to SHTM 04- 01 Water safety for healthcare premises. Replace tap strainers in all areas. AGREED
All tap strainers will be cleaned and replaced if necessary. To be complete by the end of October 2019.
Showers Shower hose lengths do not comply with Scottish Water by-laws and guidance in SHTM 04-01 Water safety for healthcare premises. Shorten hose length, or add retaining ring, to ensure that shower head cannot reach WC or drain.

Disinfect showers, hose and drain after rectification.
Shower hoses will be rectified by addition of a retaining ring. These have been ordered and will be fitted by end of September.
Water General 1 Testing has found some fungal / mould contamination and high total viable counts. Given a number of indicators the water system should be disinfected and re-tested. AGREED
The water system will be disinfected and tested prior to occupation.
Water General 2 Legionella risk assessment actions not recorded as required by HSE Approved Code of Practice and Guidance L8 - Legionnaires' disease. The control of Legionella bacteria in water systems. Legionella risk assessment insufficient to reflect system contamination in general. Those responsible for the system have a responsibility under the Control of Substances Hazardous to Health Regulations 2002 (COSHH) to prevent exposure to microorganisms. The Legionella Risk assessment Feb 2019 identified a range of actions. The Action Tracker does not demonstrate that the issues raised have been resolved or a timeline provided for resolution. Record rectification of actions. The risk assessment is heavily focussed on Legionella and not taking into account other organisms in line with patient type that will occupy the building. Broaden to reflect system contamination in general. Develop analysis categorisation of patient type and consideration to susceptibility for each area. AGREED
Changes to the water management plan have been made to reflect this.
Water General 3 Designated roles and responsibility as per SHTM 00 Best practice guidance for healthcare engineering. The current Responsible Person (RP) has not been appointed in writing and uncertain as to whether received RP training. Additionally, has no previous experience of healthcare. AGREED
The name of the responsible person has been confirmed; their qualifications will be provided.
Water General 4 Water tanks as per SHTM 04-01 Water safety for healthcare premises. To be inspected. The Raw Water and Filtrate water tanks are interconnected at the drain. These must be separated. AGREED
This work will be complete by the end of September 2019.
Water General 5 Hot and cold water temperatures / flushing. SHTM 04-01 Water safety for healthcare premises There was an issue with raised cold water temperatures during the boiler outage – this requires investigation. AGREED
Regular monitoring of hot and cold water temperatures is part of the water maintenance plan.
Water General 6 Filtration Plants From lessons learned by NSS in recent work, microbiological growth potential was identified as part of the Backwash cycle. Consideration should be given to Chlorine dioxide addition to backwash water tank to counter microbiological and biofilms development on filters. CLOSED
NHS Lothian will consider new advice as it is produced and incorporate this into the water management plan as necessary.
Water General 7 Instant Boil Taps and Rise and Fall Baths These were found to be contaminated and need to be disinfected and tested t demonstrate safe water delivery as per SHTM 04-01 Water safety for healthcare premises. AGREED
This action is underway in conjunction with the manufacturers.



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