WATER SAFETY
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.
aligned with actual clinical use rather than generic schedules.
n Reviewing outlet and drainage design to minimise splash, aerosol generation, and cross contamination between sinks, taps, hands, and nearby clinical activities.
Karina Jones
IHEEM-registered Authorising Engineer Karina Jones C.Eng. MIET. FIHEEM. MWES. M.W.M. Soc has many years’ experiences in water management, working closely with NHS Trusts and water management companies to provide independent and impartial advice across a wide range of challenges. She has extensive experience advising clients on water hygiene management and the legal drivers for statutory obligations and ACoP L8 compliance, as well as providing comprehensive guidance on microbiological waterborne contamination in water systems. Karina is a strong advocate that AEs should not only highlight areas of non- compliance but should support clients towards effective solutions. She is Fellow member of IHEEM, a Fellow member of the Institution of Engineering and Technology (IET), and a member of the IHEEM Water Technical Panel.
Addressing these root causes reduces the opportunity for pathogens to establish within systems, limits biofilm development, and diminishes the likelihood that water infrastructure becomes a persistent reservoir for infection. This is particularly important given that organisms such as NTM and MDR bacteria are highly resilient, difficult to eradicate once established, and often resistant to both disinfectants and antimicrobial treatment. Importantly, failure to tackle these foundational issues can create a cycle of dependency on additional controls – such as filters, intensified cleaning, or increased monitoring – without ever resolving the underlying problem. Over time, this approach increases cost, complexity, and operational burden, while providing only an illusion of safety. Particular attention must be given to high risk patient
environments, where the consequences of exposure are most severe and patient susceptibility is greatest, including: n Intensive care units (ICUs). n Neonatal wards and special care baby units. n Haematology and oncology units. n Transplant and other highly immunocompromised patient areas.
In these settings, even low level or intermittent contamination can result in serious infection. As such, the expectation should be that water and drainage systems are intrinsically safe by design and operation, rather than rendered ‘safe’ through layered compensatory measures alone. Ultimately, effective water safety management requires
a shift in mindset: from reacting to detected contamination at the outlet to designing, operating, and maintaining systems that minimise the opportunity for contamination to occur at all. Addressing the root causes is not only more effective in protecting patients, but also supports long term resilience, clearer accountability, and stronger assurance across healthcare organisations.
Moving forward The opportunity for the healthcare sector is not to identify fault but to strengthen collaboration between estates teams, clinical staff, and contractors. Three key principles can support this approach:
n Training as a risk-reduction tool. n Improved understanding of waterborne pathogens and system risks enables staff to recognise and manage hazards more effectively.
n NTM management should be risk-based, not test- driven.
60 Health Estate Journal October 2026
Testing should support risk management rather than drive unnecessary interventions. Filtration should be targeted, and filters should protect the most vulnerable patients where necessary but should not replace fundamental risk control measures. The publication of NHS Estates Technical Bulletin (NETB) 2024/3 represents an important and timely evolution in healthcare water safety, reinforcing the need to protect the most vulnerable patients from a broader range of waterborne pathogens, including NTM, Pseudomonas aeruginosa, and MDR organisms. However, the real challenge for healthcare organisations lies not in understanding the guidance itself, but in translating its intent into consistent, effective day-to-day practice. This article highlights that fact that the most significant risk to patient safety arises from an operational gap between estates managed water systems and the realities of frontline clinical practice and contractor activity. Water safety has historically been treated as a technical, estates-led compliance function rather than a shared, multidisciplinary responsibility directly linked to infection prevention and patient outcomes. As a result, ownership can become fragmented, training overly generic, and critical system risks insufficiently understood by those who interact with water systems on a daily basis. The increasing recognition of NTM and other resilient, treatment resistant organisms further emphasises why reactive or downstream controls alone are not sufficient. Measures such as point of use filtration have a role, particularly for protecting high risk patients or during incident response, but they do not address the underlying system conditions that allow pathogens to persist and proliferate. Without tackling root causes – such as stagnation, dead legs, poor outlet and drainage design, sub optimal temperatures, low use outlets, and inconsistent human behaviours – healthcare organisations risk creating an unsustainable reliance on compensatory controls that provide reassurance without long term resilience.
A shift in mindset Fundamentally, effective water safety management requires a shift in mindset: from reacting to contamination when it is detected, to proactively designing, operating, maintaining, and using water systems in ways that minimise the opportunity for contamination to arise in the first place. This approach aligns with the hierarchy of risk control, supports antimicrobial resistance (AMR) objectives, and provides stronger assurance for high risk clinical environments where the consequences of exposure are greatest. Moving forward, success will depend on integration
rather than escalation – integrating water safety into clinical practice, infection prevention and control education, contractor management, and everyday decision making. This includes developing role specific, practical training; clearly articulating responsibilities; fostering open communication between estates, clinical teams, Soft FM staff, and contractors; and applying risk-based, proportionate controls aligned to patient vulnerability. By addressing the foundations of water system risk and embedding shared operational understanding, healthcare organisations can ensure that the principles set out in HTM 04 01 and NETB 2024/3 are not only complied with, but meaningfully realised – delivering safer environments, stronger governance, and, most importantly, improved protection for patients.
Bibliography n NHS Technical Bulletin (NETB) No. 2024/3. https://www.
england.nhs.uk/wp-content/uploads/2024/08/prn01343- nhs-estates-technical-bulletin-2024-3.pdf.pdf
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