The "gross negligence" of an architect from Grange-over-Sands led to Britain's biggest ever outbreak of legionnaires' disease, which left seven people dead and a further 172 infected, it was alleged at court this week.
Preston Crown Court was told how a catalogue of failures by Gillian Beckingham, head of Barrow Borough Council's design services group, led to a plume of steam contaminated with the deadly bacteria spraying from the council-owned arts complex Forum 28 in the town in July and August 2002.
The prosecution alleged during the first week of the trial that Mrs Beckingham, 45, had been "instrumental" in cancelling a maintenance contract to ensure the centre's air conditioning system was free from the disease over a year before the "devastating" outbreak.
In the months leading up to the outbreak, Mrs Beckingham negotiated a new contract but omitted the maintenance of the ageing system, later found to be operating at a severely reduced capacity, paving the way for an "inevitable" outbreak, said Alistair Webster QC, prosecuting.
Richard MaCaulay, 88; Wendy Millburn, 56; Georgina Somerville, 54; Harriet Low, 74; Elizabeth Dixon, 80; 56-year-old June Miles; and Christine Merewood, 55; all from Barrow, died in August 2002 after being exposed to the Legionella bacteria.
Together with the 172 survivors, all had been in the vicinity of the town centre building prior to falling ill with the Benidorm' strain of the disease, which proves fatal in around 12 per cent of cases and can also seriously effect those already suffering ill health.
Mrs Beckingham and Barrow Borough Council deny seven counts of manslaughter, in the first corporate manslaughter case to be brought against a local authority and employee in British legal history.
Mrs Beckingham denies a further charge of breaching the Health and Safety at Work Act 1974 that she failed to take reasonable care to protect colleagues and the public. A similar charge has been admitted by the council.
Mr Webster told the trial that Mrs Beckingham, a qualified architect, was so far up the chain of command that she had acted as the council and that the two should be found guilty of manslaughter if the jury was to find that their actions had played a "significant" role in the deaths of the victims.
"The reality is that she (Beckingham) was so senior and trusted that there was nobody who questioned her decisions she was, in effect, autonomous," he said.
Mr Webster explained that Legionella thrivedin temperatures between 20 and 45 degrees, temperatures found in cooling towers of failing air conditioning systems that had not been maintained regularly.
Yet Mrs Beckingham had terminated the maintenance contract for Forum 28, held by G.S. Hall Ltd, early in 2000, he said.
He stressed that she then approached another company, Interserve, for a quote in October 2000, but did not return to the company until March 2001 to discuss details of the contract.
Following several discussions between council employees, including Forum 28 general manager Kevin Borthwick, and council employees and Interserve, water treatment was omitted from the contract.
This decision, said Mr Webster, was made even more bizarre as during this time Beckingham had sealed a contract with Interserve for maintenance, including water treatment, at Barrow Town Hall, the Dock Museum and Cavendish House.
From the termination of the G.S. Hall contract, no water testing or dosing was carried out at Forum 28 during the months leading up to the outbreak, partly due to failures from Interserve, added Mr Webster.
But commercial manager at Interserve, Stephen Maddock, had warned Mrs Beckingham that the system was in such a bad condition that it needed urgently replacing a task that would cost £125,000, said Mr Webster.
Later unsuccessful attempts were also made to raise enough cash to replace the system, which following the outbreak was found to have one cooling tower out of use and the other running at a reduced capacity.
Saying this was no excuse for taking action, Mr Webster said: "To look for funding for a new system was somewhat like looking for a new car and ignoring the fact that the brakes on your present car were dangerous and failing.
"It would be no defence to mowing down seven people and injuring scores more to say that you were sorry, but you were just thinking of changing the car, trying to borrow money to do it."
Another Interserve engineer Andy McDonald also warned Mrs Beckingham after coming across the system, which he believed was so bad he took photographs to ensure that he could not be blamed for its condition.
In reply, Beckingham said that the council had its own chemist and that she would get in touch with Environmental Health, said Mr Webster.
She then charged Mr Borthwick with the task of seeing if testing kits for the water could be provided, but he drew a blank, he continued.
It was Mr McDonald who noticed steam coming out of the side of Forum 28 in May 2002 and went to see Beckingham, who again asked for a quote, to stress that action was urgently needed.
But a quote was not provided and Mrs Beckingham did not chase it up.
"The die was cast," said Mr Webster.
"It is hard to conceive how a senior manager, with this issue of life and death flagged up for her on several occasions, could have failed to take effective action, but fail she did.
"Only she can say why she ignored the dictates of her experience, what she had been told, and common sense, but sadly ignore them she did.
"She should have satisfied herself, in taking the decisions which she took, that safety was not being compromised in the gross way in which it was."
Instead, Mr Webster said, staff at Furness General Hospital started to notice a high number of pneumonia patients on July 27 and 28, and decided to convene a meeting of the outbreak control committee, chaired by Dr Nick Gent.
The court heard yesterday (Thursday) how Philip Anthony Newton, commercial services team leader at Barrow Borough Council, had spotted "a mist" coming from the building on August 1 before contacting his superiors.
The link between the building and the outbreak was soon confirmed by tests and the system shut down at 4.30pm.
The trial continues.
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