WATER SAFETY
Water safety risk in healthcare settings
The NHS Estates Technical Bulletin (NETB) No. 2024/3 provides supplementary guidance to HTM 04-01: Safe Water in Healthcare Premises. The purpose of this bulletin is to highlight the importance of ensuring that healthcare environments are designed and managed to protect patients who are at high risk of infection from non-tuberculous mycobacteria (NTM) and other waterborne pathogens. While the principle is clear, an important question remains: what does this mean in practical terms for the day-to-day management of water safety in healthcare settings? Karina Jones, principal Authorising Engineer at Eta Projects, tells us more.
Through long-term involvement in healthcare water management, numerous conversations with professionals across the sector have highlighted a consistent and significant issue: a gap between estates-managed water safety systems and frontline clinical practice, including contractors who carry out a wide range of Planned Preventative Maintenance on water assets. There is an operational gap in existence which creates a risk. Discussions with a wide range of professionals involved in water management, including: n estates and facilities teams n capital project managers n Infection Prevention and Control (IPC) teams n soft FM staff n contractors
consistently reveal that the key issue is not a lack of awareness, but rather a lack of operational understanding and most importantly shared ownership. These discussions consistently point to a fundamental challenge: the issue is rarely a lack of awareness of guidance or risk, but rather a lack of shared operational understanding and ownership across disciplines. Water safety is often managed as an estates-
led technical compliance function, while the clinical implications of water system design, operation, and use are not always fully understood or embedded within frontline practice of clinical staff. As a result, responsibilities can become fragmented, with estates teams maintaining systems to specification, IPC teams focusing on surveillance and response, and clinical staff interacting with outlets daily without a clear appreciation of how their actions influence system risk.
The need for a shared framework This operational gap means that controls intended to protect highly vulnerable patients – such as outlet design, flushing regimes, filtration, or restrictions on water use – may not translate effectively into consistent, safe behaviours at ward level. Equally, concerns raised by clinical teams about water use or infection risk may not always be understood in the context of system design constraints or regulatory requirements. This not only apply to our clinical staff but also to contractors’ way of preforming their task of remedial actions. Without a shared framework for decision-making, water safety measures risk being seen as burdensome, impractical, or detached from patient care rather than as integral to infection prevention. Bridging this gap requires moving beyond compliance and documentation toward genuine integration of water
safety into everyday operations. This means clearer articulation of roles, improved communication between estates, contractors, and clinical teams, and practical, risk based guidance that supports staff in making safe decisions at the point of care. Only by developing a shared understanding of how water systems, human behaviour, and patient vulnerability intersect can the intentions of HTM 04 01 and NETB 2024/3 be realised in day to day clinical practice. Clinical staff have a good understanding of the infection risks associated with water systems. Most are aware that: n Legionella bacteria can proliferate in water systems and cause Legionnaires’ disease.
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Elderly patients face a significantly higher risk of infection.
n Pseudomonas aeruginosa is a significant healthcare- associated pathogen.
n Patients who are elderly, immunocompromised, or receiving critical care are particularly vulnerable. n Water outlets can act as sources of infection.
However, many clinicians are understandably less familiar with how healthcare water systems function and how risks are managed operationally. In addition, contractors attending healthcare to carry out remedial works on the domestic water systems may not always be aware of the other aspects of water management and risks, other than the task in front of them to complete. For example, the following system conditions can increase microbial risk: n Water stagnation. n Dead legs within pipework. n Sub-optimal water temperatures. n Infrequently used outlets. n Flexible hoses and complex fittings. n Scale and biofilm formation. n Poorly maintained cold water storage tanks. n Inadequate water turnover.
October 2026 Health Estate Journal 57
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