Errors 'caused disease outbreak'

The 50-page Health and Safety Executive (HSE) report identifies numerous failings and highlights how similar tragedies should be avoided in future.

Along with seven deaths, 180 others were infected after a faulty air conditioning system sprayed the deadly bacteria into an alleyway outside the Forum 28 Arts Centre in Barrow, Cumbria, in Summer 2002.

The report comes after a lengthy investigation and public meetings held in the town last December into the causes, consequences and responses to the tragedy.

Barrow Borough Council, which ran the arts centre, was cleared of corporate manslaughter, but fined £125,000 for breaching health and safety laws. The council's design services manager, Gillian Beckingham, 48, of Grange-over-Sands, Cumbria, was also cleared of manslaughter following an eight-week trial, but convicted of health and safety breaches.

Preston Crown Court heard she had failed to maintain the contracts that provided for the upkeep of the air conditioning unit.

Richard Macauley, 89, Wendy Milburn, 56, Georgina Sommerville, 54, Harriet Low, 74, Elizabeth Dixon, 80, June Miles, 56, and Christina Merewood, 55, all lost their lives.

Colin Pickthall, the independent chair of the public meetings, said: "Like most accidents, this tragedy could have been avoided if the risks had been properly managed."

The HSE report concludes there were poor lines of communication and responsibility on the part of the local council and that it failed to act on concerns that had been raised before the outbreak. There was also a failure to carry out a risk assessment and poor management of contractors paid to ensure the air conditioning system was clean and working.

Finally it says there were individual failings, but Ms Beckingham's failures were "more significant than others" and concludes: "The number of fateful 'coincidences' involved was scarcely credible. Such basic failings should not have occurred and, sadly, these failures could have been easily prevented."