NHS England business continuity management toolkit case study: interruption to hot water and heating

Organisation: University College London Hospitals NHS Foundation Trust
Incident: interruption to hot water and heating

What happened

Problems were reported with the heating and hot water on a weekday morning in January. It transpired that the problems had been caused by two boiler failures that occurred in the early hours of that morning.

The first boiler failure was due to a low gas pressure. Following discussions with the specialist contractor, it was suspected that there was debris in the gas system. The contractor was called to the site to rectify the problem immediately. The second boiler failed due to a high gas pressure; this issue was also dealt with immediately.

Due to the low external overnight temperatures, coupled with the faults described above, the boilers went into a thermal protection mode. This could not be overridden and requires a staged return, which further delayed the return to normal operating temperatures in the morning.

The effects of these faults on the building were low temperatures due to poor heating and cold water. The impacts on the services included delayed care to patients (including theatre starts and discharges), an uncomfortable environment for patients and staff to be in (including poor heating and cold water for hygiene purposes), risk of pre-operative and post-operative hypothermia, infection control issues for staff caring for patients.

Action taken

Several actions were taken to mitigate against the risk identified as a result of the boiler faults.

  • Extra blankets were ordered to keep patients warm.
  • Blinds were closed to retain heat that was there.
  • Delayed start of the operating theatres, considered as environmental risk for post-op

Lessons identified

A number of lessons were identified:

1. Increase communications between all services involved during an incident.
2. Ensure information from contractors is fully understood, including caveats, prior to
passing this onto staff and patients.
3. Ensure that internal escalation procedures are robust to that issues are escalated up
via appropriate routes.
4. Ensure that routine maintenance checks of equipment and estate take place.