Queen Elizabeth Kings Lynn

CLIENT: Queen Elizabeth Hospital NHS Foundation Trust

PROJECT DETAILS: Legionella Control Gap Analysis

NIFES ROLE: Assess the Control of Legionella bacteria in the Hospitals water systems


Queen Elizabeth Hospital is a large acute hospital sited in, Kings Lynn, Norfolk. It has many complicated and integrated water systems, which fall under the required control of legislation and the Healthcare Technical Memorandums (HTM’S). The hospital provides services for a wide spectrum of patients from high dependency; immunosuppressed to day patients and A&E services. The water systems require an assessment of risk and an application of control.


NIFES initially quantified the systems at Queen Elizabeth Hospital in 2009 which fell under the control of legislation and the Healthcare Technical Memorandums (HTM’S). Schematic drawings, risk assessment, action plan with mitigating remedial requirements and a Written Scheme of Control was produced.

Since the original assessment; annually, NIFES have carried out a gap analysis of the control of Legionella bacteria at the hospital. This gap analysis involves a fine tooth assessment of all PPM’s and procedures, policy review and a risk assessment of any system changes. The findings of the assessment are delivered in a detailed document, highlighting all categories of risk, remedial actions required and time scales; these form part of the Estates Action Plan. A Written Scheme of Control is produced, enabling the Hospital to manage their water systems.


Queen Elizabeth Hospital now has:

  • Upto date schematic drawings of the installed water systems and its associated components
  • A up-dated risk assessment of all water systems and all associated components
  • Highlighted risks, categorised with apportioned timescales and ratings
  • An Estates Action Plan, showing all risks found and remedial work required to mitigate each risk
  • A Written Scheme of Control enabling the Hospital, management of their water systems
  • Highlighted risks, of the maintenance activities associated with their water systems
  • An annual system and management health check

Queen Elizabeth Hospital NHS Foundation Trust; now have confidence & direction in the control of Legionella bacteria.