Rhoda Freedman

[Page 1] Response to Regulaon 28 Report to Prevent Future Deaths Coroner Michelle Brown, coroner for the area of Essex Date of report 31st July 2026 Name of deceased Mrs Rhoda Freeman Organisation submitting the response AquaCert Ltd Date of response September 2026 Background AquaCert have been undertaking legionella testing since 2019. These are the dates/results of the analysis prior to the death of Mrs Freedman in May 2024. Legionella were found every time apart from the test in January 2023. Date Certificate Results Sampled Reference 05-11-19 085064 1 of the 3 samples were found to contain legionella bacteria 24-11-20 101905 2 of the 3 samples were found to contain legionella bacteria 03-11-20 101655 3 of the 3 samples were found to contain legionella bacteria 20-10-21 106971 2 of the 3 samples were found to contain legionella bacteria 15-11-21 107262 2 of the 3 samples were found to contain legionella bacteria 24-11-22 113278 2 of the 3 samples were found to contain legionella bacteria 04-01-23 113732 None of the samples were found to contain legionella bacteria AquaCert:-  Have no input or control over the water systems at Wensley House.  Have no input or control over the water quality risk assessments [legally] required at Wensley House.  Have no input or control on any type of sta training at Wensley House.  Have no input or membership of the water safety group (WSG) at Wensley House.  Have no input in the development of a ‘Scheme of Control’ at Wensley House.  Have no input in deciding the sample locations or testing frequency for legionella at Wensley House. The results above would suggest that our current procedures don’t significantly impact the accuracy of the sample results and the recovery of legionella bacteria. That said, Tom Makin is highly respected and his report has highlighted areas where we can improve. The following matters were raised by the expert witness, . DOCUMENT NAME: AQC RF – – Expert Water Treatment – Hygiene Report – dated 06.07.26.docx
1. Hot water samples only
2. Combination of multiple samples
3. Aseptic sample collection procedure
4. Pre/Post flush sample collection
5. Temperature measurement and recording
6. Shower sampling
7. Biocide neutralising agent mixing REGISTERED OFFICE CONTACT AquaCert Limited TEL 01327 844848 … the first choice water testing laboratory for healthcare, iCon Environmental Innovation Centre TEL 0800 048 1737 Page 1 of 4 universities, schools, commercial property and shipping … Eastern Way, Daventry, NN11 0QB www.aquacert.co.uk

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1. Hot Water Samples Only Response AquaCert do test domestic cold water in addition to domestic hot water. Legionella can and does grow in cold water (given favourable conditions) but the ratio of positives we see is approx. 20:1 (hot:cold). Action Taken/Proposed AquaCert will advise clients that they should consider testing cold water locations in addition to their hot water ones. Timescale This will be achieved in four ways:-
1. A mailshot to all existing clients informing them that cold water supplies can also harbour legionella (approx. 6 weeks to complete).
2. Amend our website to suggest prospective clients to consider testing both hot & cold water systems (approx. 6 weeks to complete).
3. Change the structure of the legionella web page to make clients individually choose either a “hot” or “cold” legionella test kit (approx. 12 weeks to complete).
4. Verbally advise this information to clients when they order test kits direct by telephone. (approx. 4 weeks to complete). Monitoring We can review the ratio of hot:cold test kits on a 3 monthly basis, though it will take 9 months for the figures to be statistically valid.
2. Combination of multiple samples Response AquaCert undertake “indicative” or “bulk” sampling in some situations but not for all. We provide further details on this in the Supporting Document section at the end of this document. Action Taken/Proposed
1. AquaCert will amend its website to state that “bulk” sampling does not comply with BS 7592
2. AquaCert will add a comment on its certificates of analysis to state that “bulk” sampling does not comply with BS 7592 Timescale Website changes (approx. 12 weeks to complete) Certificate changes (approx. 6 weeks to complete) Monitoring AquaCert routinely monitor all sales
3. Aseptic sample collection procedure Response AquaCert provide gloves in many of our test kits such as Pseudomonas aeruginosa, potable etc. Gloves are not necessary for a “bulk” sample because water from dierent locations is being placed in the same bottle, i.e. cross contamination is being enforced. Action Taken/Proposed
1. AquaCert will review documentation sent with kits and check for clarity.
2. AquaCert will consider if we should provide a web based training course or direct clients to existing material available from 3rd party companies. Timescale Documentation review (approx. 12 weeks to complete). Decision on provision of an AquaCert web site training course (approx. 4 weeks to complete). Monitoring AquaCert intend to hold a formal review in January 2027 to check progress against our stated commitments. This will be part of the review.

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4. Pre/Post flush sample collection Response The instruction to run that tap prior to obtaining the sample was an oice error when compiling the document. Action Taken/Proposed The document has been amended. Timescale Completed the same day as the error was reported. Monitoring AquaCert will check [again] that all sta are using the revised document during the review in January.
5. Temperature measurement and recording Response The sample submission form will be amended to include a box for temperature recording. Action Taken/Proposed This change needs to be done by an external supplier as it involves computer coding. Timescale (approx. 12 weeks to complete). Monitoring AquaCert intend to hold a formal review in January 2027 to check progress against our stated commitments. This will be part of the review.
6. Shower sampling Response The AquaCert instructions require minor revisions. Action Taken/Proposed The document will be amended. Timescale (approx. 4 weeks to complete). Monitoring AquaCert intend to hold a formal review in January 2027 to check progress against our stated commitments. This will be part of the review.
7. Biocide neutralising agent mixing Response The AquaCert instructions require minor revisions. Action Taken/Proposed The document will be amended. Timescale (approx. 4 weeks to complete). Monitoring AquaCert intend to hold a formal review in January 2027 to check progress against our stated commitments. This will be part of the review.

[Page 4] Conclusions Primary AquaCert have not provided false reassurances that the water system was safe and fit for purpose. AquaCert were only responsible for testing the water for legionella bacteria. Each test during the period 2019 to 2022 was found to contain these bacteria. As an example, on our certificate from 24th Nov 2022, the text read INTERPRETATION A significant number of Legionella bacteria have been detected in Bottles 2 and 3. Your system may be colonised and represent a real risk. ACTIONS REQUIRED In healthcare, the primary concern is protecting susceptible patients, so this detection of legionella must be investigated. The system should be resampled and an immediate review of the control measures and risk assessment carried out to identify any remedial actions, including possible disinfection of the system. Retesting should take place a few days after disinfection and at frequent intervals thereafter until a satisfactory level of control is achieved. We have sent further information to you via email. Secondary The expert report uncovered several areas where AquaCert could improve its documents and procedures. Our company is committed to making changes, as detailed earlier. Supporng Documents Why Indicative Sampling is Useful.pdf

Dear Coroner, We write in relation to the Regulation 28 report which was issued in connection with the Inquest into the death of Rhoda Freedman, who was a resident of Wensley House (“the Home”). The Inquest into the death of Mrs Freedman was held at Chelmsford Coroner’s Court on 22 to 27 July 2026. Prior to and during the course of the Inquest the Home provided evidence to assist your inquiry including in relation to the water management protocols in place and the reflection which has taken place to strengthen the current systems and procedures following Mrs Freedman’s death. A Regulation 28 Report was however issued on 31 July 2026. This was issued to the Home, AquaCert and Swiftclean. In relation to the Home, the report raised the following concerns:
1. The water systems and pipework within the Home are not maintained to a sufficient standard to prevent further Legionella infections;
2. There is inadequate training for staff and management around the risks of Legionnaires disease;
3. There is no lead person with specialist and recognised training on all aspects of Legionnaires disease and risk assessments at the Home;
4. The water testing is not compliant with British Standards BS7592:2022; and
5. Risk assessments are not robust or compliant. At the outset, the Home would note that it has always had in place measures for the management of Legionnaires within the Home to include a regime of frequent flushing, descaling and annual water testing. Prior to the incident involving Mrs Freedman, these protocols had proven to be effective there being no prior positive tests. The Home has however reflected upon the circumstances known and the expert evidence received shortly before the commencement of the Inquest to consider whether there are any additional steps which can be taken, over and above those already implemented, to further strengthen the systems and procedures which the Home has in place.

[Page 2] Wensley House Residential Care Home Bell Common, Epping, Essex CM16 4DL Email: wensley.house@btinternet.com Tel 01992-573-117, Fax 01992-560-479 Before addressing the concerns identified, the Home would however make the following observations in relation to the findings set out within the Regulation 28 Report:
- Mrs Freedman did leave her room during her stay at the Home on a number of occasions. She would often go around the Home with her daughters or go out into the garden. She would also use the hairdressing salon on the ground floor and attended hospital appointments. The most recent hospital visits prior to her death were 16 January 2024 and 23 February 2024.
- The Report raises a concern that Mrs Freedman contracted Legionella from ‘a cut pipe coming from the toilet of the office into room 44’. There was however no such pipe present. Rather, between the office and room 44 there was a toilet and hand wash basin. Whilst infrequently used, these were subject to the same flushing regime employed throughout the wider Home. The toilet was however removed in June 2024 given the potential for this to create a dead leg. Water Systems and Pipework Since July 2024, the Home has engaged the service of Swiftclean, an external specialist third party water management company, to support it in treating and managing its water systems. Swiftclean is accredited to ISO9001, ISO14001 and ISO45001. Swiftclean are in addition a Legionella Control Association Member. Accordingly, the Home considered that it had contracted a suitably qualified and experienced company to support it in managing and risk assessing its water systems. Their appointment was also done with the IMT’s full knowledge who were also content with Swiftclean’s specialism in this area. Swiftclean’s engagement was on the basis of a full monitoring contract under which they would take on responsibility for all tasks to achieve compliance other than daily flushing which it was agreed would continue to be undertaken by the Home. This reflected Swiftclean’s trained engineers attending the Home on a monthly basis to complete required monitoring, cleaning and testing and providing reports and evidence of their completion.

[Page 3] Wensley House Residential Care Home Bell Common, Epping, Essex CM16 4DL Email: wensley.house@btinternet.com Tel 01992-573-117, Fax 01992-560-479 Prior to Swiftclean’s appointment, the Home had initially engaged the services of Sussex Business Compliance Solutions S.B.C.S. who produced a “Legionella Risk Assessment Report” dated 31 May 2024. This identified the toilet adjacent to room 44 as a potential dead leg, as well as the toilet next to room 45. Whilst flushed as a minimum weekly in accordance with the Home’s pre-existing water management protocols, the Home nevertheless requested that these were removed, this action being completed on 7 June 2024. The pipework was at this time capped off and a draining mechanism introduced to enable this to be flushed. Upon Swiftclean’s appointment in July 2024, they then produced an updated risk assessment which encompassed a further detailed review of the pipework and schematics prepared. The Home took a number of additional steps to review the systems in place to include as a precautionary step replacing all taps, connection hoses, Thermostatic Mixer Valves, hoses and showerheads once negative results were obtained in line with IMT guidance. All pipes were in addition insulated throughout the building and two new baths installed. Finally, a water dosing system was also introduced. This was again done with full engagement from the IMT team. These measures were taken out of an abundance of caution following the positive detection of legionella in an effort to ensure that this was fully removed from the water systems, and to prevent a reoccurrence. The Home was accordingly concerned to receive the expert evidence shortly prior to the Inquest which suggested that the measures taken, in line with IMT guidance and that received from Swiftclean, were not fully compliant. The Home has engaged with Swiftclean to address the matters raised and remains in discussions to confirm it receives appropriate assurances as to their competence to continue supporting the Home. In addition, following the Inquest all showerheads have been changed to single settings in light of the expert evidence heard.

[Page 4] Wensley House Residential Care Home Bell Common, Epping, Essex CM16 4DL Email: wensley.house@btinternet.com Tel 01992-573-117, Fax 01992-560-479 Risk Assessment Swiftclean have confirmed that they have engaged with the Legionella Control Association (“LCA”) to support in reviewing their current risk assessment processes. The LCA have as a result provided feedback to ensure Swiftclean’s systems comply with the latest LCA standards. The Home has accordingly requested that the existing risk assessment is reviewed and updated by Swiftclean at the earliest opportunity to confirm that it meets the updated LCA standards. The Home has also asked Swiftclean to confirm that following the review, they are now compliant on all measures. Training As advised during the Inquest, all members of the care team completed Legionella Awareness training following Mrs Freedman’s death. The Registered Manager, Responsible Person and a Director have now in addition completed ‘HXT-W05 Water Responsible Person Training for Healthcare Premises (HTM & SHTM)’ building further upon the training already undertaken and the experience held. This training is awarded with a City and Guilds Accredited Programme Certificate. The Home accordingly considers that all staff have received appropriate training in this regard. Lead Person The Home has now designated a lead person who has completed the ‘HXT-W05 Water Responsible Person Training for Healthcare Premises (HTM & SHTM)’ outlined above. They will in addition be attending a Competent Person Water City and Guilds accredited training course covering:  Requirements of legislation and Regulations for water distribution systems (HTM 04-01);

[Page 5] Wensley House Residential Care Home Bell Common, Epping, Essex CM16 4DL Email: wensley.house@btinternet.com Tel 01992-573-117, Fax 01992-560-479  The different waterborne pathogens and their transmission routes around the buildings water systems and equipment;  Other water safety issues in a distribution system including physical and chemical contamination;  Methods of preventing contamination and cross-contamination within healthcare premises;  Sampling requirements and methods to ensure accurate results including interpreting the results and remedial actions;  Logbook records and recording of remedial actions; and  The role of the Water Safety Group and the Water safety Plan within health care premises. This has been booked for 25 November 2026 being the next available course date. Water Testing The Home has now ceased the use of AquaCert’s services and this testing has been moved to Swiftclean. Swiftclean has confirmed that the sampling which they undertaken is in line with the British Standard BS7592 2022. Accordingly, the Home has taken steps to review the arrangements in place for the management of Legionnaires and considers these to be appropriate in all the circumstances. We hope that this response is of assistance to the Coroner in confirming the arrangements currently in place. We would like to conclude by again expressing our sincere condolences to Mrs Freedman’s family for their loss.