A four-day supply of unsafe drinking water in Gorey, Co Wexford that left 46 people ill and one person hospitalised was aggravated by human error in failing to quickly detect the problem, an investigation has found.
The “water quality incident” arose from a power failure at the Creagh Water Treatment Plant on August 19th last year which caused its chlorine dosing pumps to fail.
As a result, water entered the public supply without the appropriate level of disinfection, a situation described in an investigation report published on Wednesday as “entirely unacceptable in public health terms”.
The incident generated controversy after dozens of people in the area – early reports of 52 were revised down to 46 – consumed the water and had to attend their GPs with one them ultimately being admitted to hospital.
A report by Aengus Consulting, commissioned by Wexford County Council, found the failure of the disinfection system at the plant to be the primary cause.
“The disinfection system, consisting of sodium hypochlorite pumped into the treated water, ceased to operate due to mechanical failure but human error in not detecting and escalating the problems extended the timeline of the incident by approximately four days,” it said.
“The plant is equipped with automatic alarms alerting caretaking and supervisory staff but these alarms proved ineffective in alerting Wexford County Council staff that a serious situation had occurred at the plant.”
The report also noted the chlorine alarm system was on a “low priority setting” and did not issue text messages to council staff.
The supply of poor water quality only came to light four days later when complaints from Gorey residents to Irish Water were passed on to Wexford County Council. At that point both the Environmental Protection Agency and HSE were alerted.
Aengus Consulting examined all the materials and interviewed all relevant people in connection with the incident.
Wexford Fianna Fáil Senator Malcolm Byrne, who was vocal on the episode last year, said measures taken to address the causes of the incident were welcome but that “reassurances are needed that this will not happen to any other community in Ireland”.
Mr Byrne noted that more than €2 million is now being invested in the plant’s improvement but said it was worrying so many people had been made sick by the incident.
“The delay in recognising the problem that occurred resulting in inadequate dosing of chlorine for a period of three to four days was entirely unacceptable in public health terms,” the report noted.
“It is now certain that there was human failure and a lack of supervisory oversight on the Creagh plant.” Organisational and operational changes are required to address the deficiencies and to avoid a future recurrence, it stated.
Investigators also found that, while plant operators are trained, it is “obvious” further ongoing training is required.
There has been limited compliance with the Irish Water Standard Operational Procedures by Wexford County Council staff, it said, although their rollout was affected by Covid-19.
“Significant improvement is required in the organisation of staff workshops to engender a shared responsibility which is a duty of care towards water customers,” the report said.
In response to various recommendations set out in the report, the council said a new alarm for power failure has been put in place, as has an emergency power generator.
Despite some staffing constraints, the local authority said it had appointed a caretaker for the Creagh plant who is fully assigned to the water treatment plant operation.
An audit of all water treatment plants in the county is due to be completed at the end of June. Meanwhile, Irish Water is conducting an alarm review of all plants throughout the county as part of a national programme of inspection.
