From Unconscious incompetence to Conscious competence – learnings from a Legionella Outbreak

Kathy Taylor 1

Infection Control Manager, The Wesley Hospital, Toowong, QLD, Australia


Introduction: In June 2013 the Wesley hospital made the national news because of a Legionella outbreak. The 524 bed private hospital reported two immune-compromised patients had contracted pneumonia whilst they were inpatients at the facility. Investigations revealed the Legionella was in the potable water system of the hospital.

Methods: Initially there was a lack of guidelines for the management of legionella in potable or drinking water systems, there were many guidelines for managing legionella in cooling towers, but not a lot of guidance for remediation of a drinking water supply that was infected by Legionella bacteria.
External experts were sought to assist the Wesley work towards a safe water supply for the complex water systems within the hospital. There are approximately 3,000 water outlets and 16 kilometres of pipes within the building complex, so initially the remedial work was done with the approach of “curing” the water system of legionella.

Results: Australian guidelines for Legionella control in the operation and maintenance of water distribution systems in health and aged care facilities were published in January 2016. Queensland parliament will make compliance with the enhealth guidelines compulsory for all healthcare facilities in Queensland. Part of this compliance is having a Water Quality Risk Management Plan (WQRMP) in place.

Conclusion: A multi-level strategic approach is needed for managing Legionella and other water born bacteria within a water distribution network and these strategies now form the basis of the WQRMP for the Wesley.

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