Graham Butterworth died on 5 December 2017 after contracting Legionnaires’ disease while serving a prison sentence at HMP Lincoln.

Water samples from Butterworth’s cell and nearby shower blocks tested positive for legionella days after the 71-year-old died.

An HSE investigation found Amey Community Limited, which provided facilities management services at HMP Lincoln, failed to act on a risk assessment carried out in 2016, failed to put in place a written scheme for preventing and controlling legionella risks, failed to ensure that appropriate water temperatures were maintained and failed to monitor water temperatures in the water system in October and November 2017. This allowed legionella bacteria to multiply rapidly.

Amey Community Limited, of London, pleaded guilty to safety breaches and was fined £600,000 and ordered to pay £15,186.85 in costs at Lincoln Magistrates’ Court this week.

HSE inspector Stacey Gamwell said: “There is a legal duty to keep workers and inmates safe in prisons. The occupants of HMP Lincoln had been put at risk of legionella bacteria and developing Legionnaires’ disease because of Amey Community Limited’s failures.

“Companies such as Amey Community Limited need to ensure they have identified any risk of legionella and have suitable and sufficient arrangements in place for managing the risk and control measures they have implemented.