WATER SAFETY
a critical risk that must be managed carefully, experience across healthcare settings increasingly demonstrates that outbreaks and patient harm are frequently associated with other waterborne organisms. In particular, Pseudomonas aeruginosa is commonly
linked to taps, sinks, drainage systems, and water outlets, especially within critical care, neonatal, burns, and immunocompromised patient environments. Transmission pathways may include: n Splash contamination from sinks and outlets. n Aerosol generation from showers or certain types of taps. n Contact with contaminated surfaces, equipment, or hands following sink use.
Multidrug resistant (MDR) waterborne organisms are increasingly prevalent.
n Inadequate level of cleaning of tools used for remedial works.
n Hand hygiene.
These operational risks are often overlooked and even though they are well understood by estates teams they can be less visible to the larger clinical staff, even though day-to-day behaviours within clinical areas can influence these risks.
The role of training One of the key reasons for this gap lies in how training is currently delivered. In many organisations, water safety training for clinical
staff, support staff (Soft FM) and contractors, is limited to generic eLearning modules or brief, compliance-focused toolbox talks. Contractors may receive only induction level information, often heavily procedural, with little emphasis on the ‘why’ behind controls or on their personal role in managing water safety risks. As a result, training tends to become a tick box exercise rather than a foundation for informed decision making and real accountability. These approaches typically prioritise regulatory compliance over practical, operational understanding and are rarely tailored to the specific roles, responsibilities, or working environments of clinical teams, Soft FM staff (such as cleaning personnel), or external contractors. This can lead to a fragmented understanding of risk, where responsibility is assumed to sit elsewhere – often with estates – rather than being shared and actively owned by all parties who interact with water systems. Conversely, technical guidance such as HTM 04 01 is
often highly detailed and written primarily for engineering and estates professionals. While technically robust, this guidance does not always translate easily into practical, role relevant knowledge for clinicians, Soft FM teams, or contractors who may be undertaking tasks that directly affect water safety, such as outlet cleaning, maintenance activities, or system modifications. The challenge, therefore, is not a lack of available
knowledge, but a failure of communication, relevance, and engagement. Clinical priorities understandably focus on immediate patient care, while contractors may focus on task completion and contractual scope. Infrastructure related risks can therefore appear remote unless they are clearly explained within a clinical, patient safety, and accountability context that makes individual responsibilities explicit and meaningful.
Legionella is not the only risk Traditionally, healthcare water safety training has focused heavily on Legionella control. While Legionella remains
58 Health Estate Journal October 2026
In addition to Pseudomonas, NTM represent a growing and often under recognised challenge across healthcare. NTM are naturally present in water systems, are highly resistant to standard disinfectants, and can readily persist within biofilms in pipework, outlets, and drainage systems. In vulnerable patient populations, particularly those with weakened immune systems, NTM can cause serious and difficult to treat infections. Compounding this risk is the increasing prevalence of multidrug resistant (MDR) waterborne organisms. Healthcare water systems can function as long term reservoirs for antimicrobial resistant bacteria, allowing organisms to persist, adapt, and spread within clinical environments. This significantly increases the consequences of exposure, as treatment options may be limited and patient outcomes more severe. Despite these risks, training and awareness programmes
often remain narrowly focused on Legionella compliance. This can result in a false sense of security, where risks associated with sinks, outlets, drainage design, outlet usage, and routine activities are underestimated or overlooked – particularly by clinical staff, Soft FM teams, and contractors who interact with water systems daily. For these reasons, water safety training should move
beyond a narrow ‘Legionella awareness’ model and instead adopt a broader, more clinically relevant framework, such as:
n Water safety, drainage management, and waterborne infection control
This wider perspective better reflects the full spectrum of microbiological risks present within healthcare water systems, including NTM and MDR organisms. Crucially, it reinforces the link between infrastructure, human behaviour, and patient safety, supporting a more informed, shared understanding of responsibility across estates teams, clinical staff, Soft FM personnel, and contractors. By framing water system risks in terms of real clinical consequences – rather than isolated regulatory requirements – training can better support effective risk ownership, safer working practices, and stronger infection prevention outcomes.
n Bridging estates and clinical practice The gap between estates-managed water safety systems and clinical practice is structural rather than cultural. Water systems are typically managed by estates or facilities teams, meaning that clinicians often view water safety as an infrastructure issue rather than a shared responsibility. However, frontline staff play an important role in
identifying potential risks. Examples include: n Recognising rarely used outlets. n Reporting poor flow or temperature irregularities n Understanding when certain outlets should be removed or restricted in high-risk areas.
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