Buchanan and St Ambrose Independent Review: final report

Chapter Six: Water Quality

6.1 According to the information available, concerns of "blue" water coming out of taps in the school were first raised in October 2013.

6.2 The history of these issues and response can be summarised as follows.

6.3 Balfour Beatty took samples on 7 Oct 2013. We do not have sight of those results, but the maintenance record reported "no issues with samples". That situation is recorded as "closed off" on 23 October 2013.

6.4 After the concerns raised on 22 October 2014, samples were taken on 12 November 2014 but we were unable to identify the results from the material submitted. The focus of attention at this time was the Home Economics department in Buchanan High School. Later reports of blue water on 26 November 2014 and 15 May 2015 focused on the cold water storage tank. On 7 October 2015, facilities staff on site were instructed to "run water until clear in line with water regulators guidance".

6.5 Further reports of blue water were received on 1 December 2015 and the cold water storage tank was again cleaned and chlorinated along with relevant pipework. The problem didn't go away and on 28 November 2016, the decision was made to trace and replace the pipework in the Home Economics area of Buchanan High School.

6.6 On 19 April 2017 following continuing concerns, work was begun to replace supply pipework to the Home Economics area. This was completed on 23 February 2018. There is a report from Scottish Water that they visited the school on 5^th May 2017 and took samples at that time which were given a "pass". No further details were available to the review team.

6.7 On 29 March 2018, reports of "black water" were noted in the Medical Room at Buchanan High School and a contractor tasked to investigate. The contractor reported that high temperatures in Buchanan High School cold water supply was increasing the likelihood of corrosion in the pipes and explained the observed "black bits". Weekly flushing of taps, re-sampling and replacing copper pipework or treat with biocide were recommendations. Instructions to facilities staff to run water through taps until clear were given again.

6.8 Following further reports of discolouration in the water on 16 October 2018, further steps were taken to "Install filters at various locations and trace/identify pipework. Alter pipework to supply toilets from mains, clean & chlorinate cold water storage tank, chemically clean pipework". On the same day, the Maintenance Team requested sampling of the water. This was undertaken but results which came back on 13 November did not include assessment of copper levels. On 19 November 2018, the Maintenance Team requested Environmental Protection services to take chemical and bacteriological samples of the water.

6.9 Results from these samples were received on 23 November and were found to have higher than quality standards of copper. No other anomalies were detected. Alternative sources of drinking water supplied to the school on 26^th November 2018. On the 28 November, the maintenance manager decided to replace 1800 meters of internal pipework in the school.

6.10 On 3 December 2018, daily sampling of water was commenced but we have been unable to find the results of these tests. The following day, Scottish Water became involved. They reported on 5 December^[40] that no bye-laws had been breached and recommended replacement of internal pipework which had already been initiated by the maintenance manager.

Summary of results taken by Scottish Water December 2018

Sample Date	Sink at snack bar	Room G036	Room G024	Room 099C	PCV (standard)
10/12/18
Copper mg/Cu/l	0.042	2.348	0.041	13.523	<2 mg/Cu/l
Total Bacterial Count at 37 degrees Celsius	0	0	0	0	0
Total Bacterial Count at 22 degrees Celsius	0	0	0	0	0
Total coliforms	0	0	0	0	0
E.coli	0	0	0	0	0

6.11 Over the Christmas holidays, the new pipework was installed, flushed and re-sampled throughout the school with the exception of its internal main supply pipe which was planned for replacement in the summer holidays when there was more time for this highly disruptive task to be completed. Samples subsequent to pipe replacement were reported within tolerance levels on 18 January 2019.

6.12 An extract of results from the various water samples undertaken on behalf of North Lanarkshire Council is presented in the table below, reporting on copper and bacterial levels.

6.13 Given the health concern raised about arsenic described earlier in this report, these levels are also reported but, like all other chemical measures, were within acceptable limits.

Summary of relevant water sampling results undertaken by North Lanarkshire Council

Sample Date	Home Economics (Buchanan)	School Kitchen (shared between schools)	Staff Room (St Ambrose)	Water Cooler (close to entry point of mains supply)	PCV (standard)
19/11/18
Copper mg/Cu/l	7.489	3.68	0.111	0.034	<2
Arsenic Micrograms/As/l	<0.9	<0.9	<0.9	n/a	<10
21/11/18
Total Bacterial Count at 37 degrees Celsius	0	>300	>300	66	0
Total Bacterial Count at 22 degrees Celsius	0	4	35	50	0
Total coliforms	0	0	0	0	0
E.coli	0	0	0	0	0
13/12/18
Copper	0.061	0.013	n/a	n/a	<2
Arsenic	<0.9	<0.9	n/a	n/a	<10
8/1/19
Total Bacterial Count @37 degrees	n/a	n/a	0	n/a	0
Total Bacterial Count @22 degrees	n/a	n/a	1	n/a	0
Total coliforms	n/a	n/a	0	n/a	0
E.coli	n/a	n/a	0	n/a	0
22/2/19
Copper	0.015	0.011	0.013	n/a	<2
Arsenic	n/a	n/a	n/a	n/a	<10

n/a = not available

Risks from copper and comments on results

6.14 We should set out the background in relation to risks from copper to humans.

6.15 The WHO guidelines on drinking water for copper (Fourth Edition)^[41] states (page 224/225):

"Copper

Copper in a drinking-water supply usually arises from the corrosive action of water leaching copper from copper pipes in buildings. High levels of dissolved oxygen have been shown to accelerate copper corrosion in some cases. Concentrations can vary significantly with the period of time the water has been standing in contact with the pipes; for example, first-draw water would be expected to have a higher copper concentration than a fully flushed sample. High concentrations can interfere with the intended domestic uses of the water. Staining of sanitary ware and laundry may occur at copper concentrations above 1 mg/l. At levels above 5 mg/l, copper also imparts a colour and an undesirable bitter taste to water. Although copper can give rise to taste, it should be acceptable at the health-based guideline value of 2 mg/l."

6.16 The guidance also has a chemical fact sheet on Copper (page 340/341) which provides the basis of the guideline value of 2.0mg/Cu/l. This is the standard which is used in Scotland as reported in the HPS report Suggested Health Risk Action Values May 2019. It is worth noting that to assess health risks, total daily doses need to be taken into account. A concentration of 2.0mg/L means a whole litre of water needs to be ingested to take in 2.0mg of copper.

6.17 Drawing this into the current circumstances on site, a level of <2.0mg/Cu/l is recommended to avoid gastric irritation. Prior to replacing the pipework, there were levels higher than this and given the fact there were reports of blue water for many years, there was a risk that people would feel sick and possibly vomit if they drank significant quantities of this water. Copper is a powerful emetic so high levels in drinking water usually result in vomiting. The review team has not received reports of vomiting after ingestion of water at the school. Higher concentrations of copper also produces a metallic taste making it less palatable to drink which means the total intake is likely to be low. As mentioned in the health section of this report, copper does not have any long-term health problems. It is not carcinogenic, nor has it been reported to cause problems for pregnancy.

6.18 The low levels of copper in the water cooler sample which is taken from a point close to the mains supply suggests the problem of copper in the water is related to internal plumbing and not an external source. There is no evidence of seepage from ground water into the water supply in the school. The mains pipe was iron cladded to eliminate this risk.

6.19 Levels of arsenic were reported low in all samples where it was tested and regarded as within safety limits. Arsenic cannot be regarded as a health risk from the water supply in the school.

6.20 Total bacterial counts (TBC) in drinking water should be below 100/ml. Samples taken on 21^st November in school kitchen and staff room at St Ambrose had levels above this. There were no coliforms or E.coli reported in these samples which means these bacteria were not likely to be derived from faecal contamination. WHO and the International Water Association reports that there is "no direct relationship between HPC (aka TBC) values in ingested water and human health effects in the population at large". It was likely to be a local contamination in the taps as the cold water temperature had been reported elevated on many occasions in maintenance reports we reviewed. After replacement of pipework, bacterial contamination was eliminated from the staff room. Results from other areas are not available. We were referred to technical data on bacterial counts set out in Health Protection Scotland information on Additional information on the Colony Count.^[42]

Cause of blue water at the schools

6.21 Following the removal of copper pipes from Buchanan and St Ambrose schools, there were inspections of their surfaces which showed the build-up of blue-green copper salt deposits. In April 2019, a consultant report^[43] provided further explanations into the cause of this build-up. When exposed to fresh, running water, new copper pipes form a protective layer of dull red-brown cuprous oxide which prevents the build-up of other copper salts when the water lies stagnant (and the oxygen levels in it fall). In the absence of this layer of cuprous oxide, copper reacts with water in different ways to produce blue-green salts. This build-up can be friable (easily crumbled) and generate "bits" as observed in reports of concerns. Best practice guidance for new buildings which use copper pipes is to flush water regularly in the first few weeks of their installation to build up the layer of cuprous oxide which is necessary to prevent other salts forming between copper and stagnant water.

6.22 The provision of water suitable for drinking and other typical uses in buildings where people live and work comes through piping designed to exclude contamination of the water by contaminants in the ground through which the pipes pass. In the case of these schools, water pipes were protected by wrapped ductile iron, as previously suggested be done in site preparation work. The time for this review does not allow us to explore other options for piping in a new school.

6.23 That said, given public concern, we considered carefully whether containments from the surrounding site could have penetrated the water supply to the school. We discount that risk for three reasons. Firstly, the water supply comes from the nearest mains public supply and there is no suggestion that blue water comes from or is present in the mains supply prior to reaching the school or is present in houses in the vicinity of the school. Secondly, as the testing shows, the incoming pipe to the school (close to the water cooler) had satisfactory levels of copper, removing this as a possibility. Thirdly, as the fuller results from chemical analysis shows, the only elevated compound from the taps in the school was copper.

Further Actions by North Lanarkshire Council to address the blue water issue

6.24 The steps taken to identify and address the problems are the provision of free-standing water coolers, further sampling and work to replace the water mains supply within the school over the Summer holiday period 2019 and this work is scheduled to be completed in time for term starting on 12 August. Completion will mean that full replacement of all original water supply pipes will have occurred.

Validation of water quality – review sampling

6.25 In line with our remit to provide further reassurance to the public, we considered that it was appropriate and necessary to ask Scottish Water (SW) to go on site and carry out testing in a range of ways of water for the presence of risk indicators before we reported.

6.26 SW did so on 8 July and summarised their findings (which are to be understood as relating only to the context of the narrated failings), as follows:-

• The water being provided to the site meets all of the drinking water standards

• Where Scottish Water samples aligned with North Lanarkshire Council (2 points) there is good correlation between these results and the most recent ones taken by the Council and the water meets drinking water quality standards for both first draw and flushed conditions.

• The first draw samples for Buchanan Science room G 051, Buchanan Art room G 036, Buchanan Room G 099A and St Ambrose Science 8 Room 2 065 show elevated levels of Nickel, Zinc, Iron and Lead (for the St Ambrose Sample). The Nickel results from the two Buchanan HS class rooms (G036 and 099A) were in excess of the PCV [Prescribed Concentration or Value] as was the Iron from St Ambrose (Room 2 065) class room. Once flushed the analysis show that all samples from these points were compliant with drinking water quality standards. This does however indicate that the local plumbing apparatus – taps etc. should be investigated for these points.

• There was one sample - Buchanan Science room G 051 – where flushing resulted in the water appearance becoming "slightly hazy" and in fact the turbidity [haziness] test for this sample did fail at 4.5 NTU – the only other parameter which was slightly elevated from this sample was Copper at 1.7 mg/l. Scottish Water were keen to know how this classroom is supplied and what the wider pipework within the building is made of or if there is a tank in the system – it maybe that there is residual material sitting in the pipework somewhere that needs to be flushed out.

• With regards to other metals such as Arsenic, Cadmium and Chromium, SW did not find anything of concern in any of the samples they took and analysed, with the results being well within the respective drinking water quality standards.

Buchanan HS	SNACK BAR	HOME ECONOMICS ROOM G 024	SCIENCE ROOM G 051	ART ROOM G 036	ROOM G 099A	PCV (standard)
8/7/19
First flush samples
Copper mg/Cu/l	0.034	0.034	0.679	0.099	0.038	<2
Arsenic Micrograms/As/l	0.2	0.2	0.2	<0.2	0.2	<10
Flushed samples
Copper mg/Cu/l	0.018	0.022	1.682	0.113	0.017	<2
Arsenic Micrograms/As/l	0.2	<0.2	<0.2	0.2	0.2	<10
St Ambrose HS	SCIENCE 8 ROOM 2 065	SCIENCE 9 ROOM 2 064	ROOM 1 033 HE 2	MUSIC BASE ROOM G 148	Only 4 samples
8/7/19
First flush samples
Copper mg/Cu/l	0.261	0.09	0.055	0.02	-	<2
Arsenic Micrograms/As/l	0.2	0.3	0.2	0.2	-	<10
Flushed samples
Copper mg/Cu/l	0.088	0.018	0.084	0.01	-	<2
Arsenic Micrograms/As/l	0.2	0.2	0.2	0.2	-	<10

Summary of Scottish Water Sample results taken 8 July 2019

Summary of other findings from Scottish Water samples taken 8 July 2019

Buchanan HS	SNACK BAR	HOME ECONOMICS ROOM G 024	SCIENCE ROOM G 051	ART ROOM G 036	ROOM G 099A	PCV (standard)
8/7/19
First flush samples
Nickel Micrograms/Ni/l	1.2	0.2	9.1	40.3	175.4	70 (WHO guideline)
Zinc Micrograms/Zn/l	43	9	375	569	599	n/a
Flushed samples
Nickel Micrograms/Ni/l	0.2	0.2	0.5	0.4	0.4	70 (WHO)
Zinc Micrograms/Zn/l	3	3	28	4	7
St Ambrose HS	SCIENCE 8 ROOM 2 065	SCIENCE 9 ROOM 2 064	ROOM 1 033 HE 2	MUSIC BASE ROOM G 148	Only 4 samples
8/7/19
First flush samples
Iron Micrograms/Fe/l	295	51	49	44	-	200
Lead	8.1	0.9	<0.2	1	-	10 (soon to be 5)
Flushed samples
Iron Micrograms/Fe/l	38	34	30	37	-	200
Lead	0.4	<0.2	<0.2	<0.2	-	10 (soon to be 5)

Validation of water quality – view of the Drinking Water Quality Regulator

6.27 Scottish Water undertook the water testing, as the appropriate body with responsibility and expertise under relevant legislation to carry out this work. SW are accredited for drinking water sampling and testing.

6.28 The Scottish Drinking Water Quality Regulator has supervised and checked the work of SW in the recent testing commissioned by the Review and is broadly satisfied that the work carried out by SW has been done to a standard and quality sufficient to give public assurance and confidence in the outcome of such testing.

6.29 The summary of her views is set out in her letter of 31 July 2019.^[44]

6.30 In that letter, she concludes:

"I recommend that Scottish Water carries out an investigation of pipework arrangements at the campus in conjunction with North Lanarkshire Council, in particular to assess the reason for the sample results from Buchanan Room G051 and that additional samples for metals in first draw and flushed samples are also taken. This will then allow Scottish Water to advise North Lanarkshire Council on any further action that may be necessary to ensure that the water supplies meet the required drinking water quality standards. The Regulations place a duty on Scottish Water to investigate sample failures in these circumstances and provide advice to the building owner of steps they need to take."

6.31 On receipt of accredited test results of samples taken by Scottish Water on 8 July, the review team asked Scottish Water and North Lanarkshire Council to work together to make a more detailed assessment, including wider sampling beyond the areas initially requested, to provide further reassurance of the water quality in the school. Scottish Water met with North Lanarkshire Council representatives at Buchanan and St Ambrose High Schools on 30 July, reviewed building plumbing drawings and discussed work completed on the internal mains water system and the ongoing work on the boosted cold water system. In addition several sink taps were inspected and confirmation of fittings compliance with the Water Regulations Advisory Scheme (WRAS) or equivalent was requested. A further sampling and analysis plan has been devised and will be carried out on areas within the school that are connected to the mains water system, in the week commencing 5 August. As at the finalisation of our Report, we do not have the outcomes of this work, but make recommendations that we consider are sufficiently flexible to provide the safe provision of potable water.

Conclusions

6.32 We conclude that staff were right to raise concerns about copper in the drinking water supply and these were not addressed seriously or quickly enough by North Lanarkshire Council. Fortunately, that work has identified no significant health impacts either short or long term from drinking the water. Replacement of pipes and following Scottish Water's advice subsequent to their recent sampling should address the problem on a permanent basis.

Recommendation

6.33 In light of the conclusions in this Report concerning water (a) having regard to the comments of the DWQR concerning the sample results from Buchanan Room G051 (b) because of the work not yet completed and verified to replace the main water supply pipe within the school (c) because of the need for public confidence in the water supply, we consider that further water sampling should be undertaken to confirm that the water supply is and remains compliant with drinking water quality standards and give confidence in the potable water being used by pupils and staff within the school in accordance with Scottish Water requirements.

6.34 Work by SW continues and we consider that this should be done in a way consistent with the places and contaminants sampled for over the Summer break and consistent with the SW methodology and the advice from the DWQR in terms of her letter of 31 July 2019 and should be done in three phases-

• within 14 days of the replacement of the main pipe within the campus (or within 14 days of today, if later);
• by the return to school after the October 2019 break; and
• by the start of term in January 2020.

6.35 Consistent with standard procedures, Scottish Water will refer matters to the DWQR if required by the DWQR in accordance with standard procedures where results are positive.

Steps taken by North Lanarkshire Council to address concerns about water quality

6.36 We are conscious of how easy it is, with hindsight, to be critical of responses to events which are only fully understood later and when the seriousness of events is clear. Not all concerns requiring the attention of a local authority take the turn that events at this campus did.

6.37 We say that specifically in this context because of criticism from some that North Lanarkshire Council sought to hid or underplay the presence of water contamination when first noted and/or that early steps to local staff on how to address concerns were inadequate.

6.38 Taking a suitably precautionary approach to human health, North Lanarkshire Council, when first being alerted to these concerns took measured and proportionate steps such as cleaning pipework and instructing the flushing of taps to clear the blue discolouration.

6.39 However, if in doubt and a situation is not resolving satisfactorily, a low threshold for involving others with expertise is to be encouraged. For example, earlier communication with North Lanarkshire Council Environmental Protection would have led to more active management of the situation and through them, Scottish Water and NHS Lanarkshire public health could have been alerted earlier to assess any potential health risks.

6.40 It appears to us that North Lanarkshire Council did take these matters seriously enough to prompt sampling work in November 2014.

6.41 However, given the regularly recurring reports of blue colouring (albeit in what was described as isolated areas) over a period throughout 2015 and less frequently but regularly until October 2018, it does seem surprising (a) that no further testing was done and (b) that there appeared to be little sense of urgency or awareness that these recurring events could impact and were impacting on confidence in the safety of the water supply on the campus.

6.42 By 2015 the campus had been operating for some time and we consider it reasonable to say that there should have been earlier sight of the problem by others beyond the local maintenance team. There may of course be problems in a new building, but after two or three years, the building is no longer new. We consider that flushing was not working. It should in our view have been clear that something else was needed to be done or considered. We are surprised that there was no apparent recognition that it is not or should not be common for a new building to continue to have this kind of problem.

6.43 Events accelerated in October 2018 with a range of reports of blue water, leading to further chemical water and bacterial water testing in November 2018.

6.44 The consultant's report in April 2019 (see paragraph 6.21 above) is useful as it sheds significant of light on the problem and should in our view have been sought much earlier.

6.45 We haven't found it easy to fully see and understand the historical timelines on these concerns and the steps considered and taken, to reach definitive views on whether different steps might have been more appropriate. Precise information about testing results between 2014 and 2018 (done by the then service provider to North Lanarkshire Council) is not easily ascertained. This is not to say that there was a problem and we are not certain whether such testing was in connection with concerns or was on a more routine basis. However, this gives rise to two observations – that this uncertainty ran the risk of fuelling public concerns about the situation and, more speculatively, could have had the effect of under-mining the ability of North Lanarkshire Council officials to satisfy questions on the detail at the public meeting on 6 June. Certainly there was confusion that evening between the date Environmental Protection Services were made aware of the problem and the duration of concerns of staff in the schools.

6.46 The lack of clarity on the audit trail and the limited appreciation of the potential impact on confidence in the school and its water safety seems to us to have spilled across to communications with unions – both NASUWT and the EIS. We comment on that relationship in Chapter 10 and in this context observe (without commenting on the merits) that water concerns in relation to a possible cancer link were first raised by NASUWT on 26 September 2018 yet by 4 February 2019 they were emailing North Lanarkshire Council regarding their disappointment of not being kept up to date with councils investigations into staff members' concerns.

6.47 We accept that, on each occasion tested, the results were (a) consistent and (b) such as indicated no cause for public health concerns, but the unwillingness of North Lanarkshire Council to proactively undertake basic water testing in order to assure and re-assure parents, pupils and staff that the water was and is safe is disappointing and suggests a failure to appreciate the impact that the uncertainty about the safety of water supply was having on staff, pupils and parents. It is well known that there is no eating or drinking in science laboratories in schools. A precautionary approach would have considered similar instructions in other parts of the school or labelling certain taps not for drinking.

6.48 In addition we had some concerns about the form of communications to the public. Although there was good quality written information provided, we consider it was issued later than it should have been. North Lanarkshire Council failed in our view to recognise early enough that, face-to-face meetings could have helped identify those who are most concerned and provide them with answers to their questions (including unions who had raised their concerns some months before a meeting was held with North Lanarkshire Council). We comment on communications in more detail in Chapter 10.

6.49 On more minor points about the information provided in the North Lanarkshire Council leaflet, referencing flushing seems to us to add little, since flushing was already failing to deal with the blue water problem. In addition, on reporting on water sampling from December 2018, there was no acknowledgement in respect of what the results looked like previously.