Company fined £20k after care home exposed to carbon monoxide

Friday 03 May 2019

A gas company has been fined £20,000 after their director's failure to properly check a boiler led staff and elderly residents of a local care home to experience symptoms of carbon monoxide poisoning.

Gas Services (Jersey) Limited was also ordered to pay £2,000 towards the prosecution for what was described as a "serious breach of health and safety obligations" while working at L'Hermitage Care Home.

The Director of the company, Ian Mawson, appeared in Royal Court on Friday having admitted the breach.

The Court heard that Gas Services had been sub-contracted to service and repair gas appliances at L’Hermitage Care Home in St. Peter, which has 42 beds.

On Friday 9 March 2018, Arron Mawson, one of the company’s directors and a trained gas engineer, was working on a boiler which had been taken out of service. He was also due to carry out annual safety checks and service the other boiler and gas-fired appliances on site.

Pictured: L’Hermitage Care Home, which has 42 beds, is located in St. Peter.

Once on site, he realised that the portable combustion gas analyser provided by the company – which was described by a Gas incident investigation officer as “essential” to check combustion is safe - was not working, but decided to get on with the work anyway.

The Court heard that there was neither a policy in place for employees to check the analyser before attending a job, nor one setting out what to do in case the analyser failed.

Mr Mawson carried out a visual check of the boiler's flame to ascertain how well they were combusting and conducted a test on each of the flues (ducts for smoke and waste gases), which involved placing a smoke pellet at the base of the flue and visually checking for smoke rising from the roof. 

He then left the site, without carrying out this analysis. The Court heard that, in not doing so, he failed to establish the levels of carbon monoxide the boilers were producing. 

In interview, Mr Mawson said he was planning to return on the following Monday to complete the work.

Pictured: The engineer carried out visual checks of the boiler's flame.

Later on that day, staff and residents at L’Hermitage began suffering from symptoms that may be associated to carbon monoxide poisoning – including headaches, feeling unwell, elevated pulses, blurred vision and difficulties in balancing and walking. These symptoms got worse until the gas emergency service was called on the Sunday.

A Jersey Gas engineer carried out a combustion check on the boiler Mr Mawson had been working on, which returned an “off the record” reading. Another two boilers were also found to have poor combustion and the engineer labelled all of them as “immediately dangerous.” 

It was discovered the following day that one of the flues – which Mr Mawson said he had been unable to check as they were in a cupboard and covered in insulation - had come apart. 

A Gas incident investigation officer considered that the speed at which people became ill strongly suggested that the flue was affected while the boilers were being serviced. He also noted that Mr Mawson left three of the boilers operating poorly, without warning staff at l’Hermitage.

Pictured: The disconnected flue was located near the roof.

Crown Advocate Matthew Maletroit described the incident as a “serious failing” as work fell “far below the standards.” He added that there was a high risk of harm as exposure to carbon monoxide can potentially have fatal consequences.

He explained he would have moved for a £75,000 fine, but instead opted for £35,000 in view of the company’s financial situation.

Advocate Christina Hall told Court that Mr Mawson wouldn’t have been able to check the flue because “you would have to come into the roof crawling" to access it.

She reminded Court the company had a good safety record and described the actions of the day as a “bad judgment call.”

Pictured: The company's lawyer said a £35,000 fine would bankrupt them.

Advocate Hall said Gas Services had since taken “appropriate steps” to ensure such a situation doesn't arise again, including the purchase of “top of the range” equipment and visual aids to replace old checklists, as well as the implementation of new processes.

She warned the Court the company couldn’t afford a £35,000 fine and would have to lay off some employees. She even went as far as to say that the company would go bankrupt, which she said was “no dramatisation or exaggeration.” However, she noted that the directors were confident they could make a £15,000 payment. 

The Lieutenant Bailiff, who was sitting with Jurats Jane Ronge and Gareth Hughes, eventually fined the company £20,000 and gave them 18 months to pay. He also ordered them to pay £2,000 towards the prosecution costs, which were in excess of £18,000.