The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust


Legionella Control Gap Analysis

  • Assess the Control of Legionella bacteria in the Hospitals water systems

The Queen Elizabeth Hospital is a large acute hospital sited in King’s 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.

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NIFES initially quantified the systems at Queen Elizabeth Hospital 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.


Project Results

Queen Elizabeth Hospital now has:

Up to date schematic drawings of the installed water systems and its associated components

An 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

The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust now have confidence and direction in the control of Legionella bacteria.