A hospital has been condemned for ignoring safety guidance which led to a man dying from Legionnaires' disease caught from a dirty shower head.
Daryl Eyles, 37, had just been given the all-clear from doctors treating him for leukaemia when he took a shower at Bath's Royal United Hospital (RUH).
The hospital pleaded guilty to charges that it carried out "inadequate" safety checks on its water system.
Bath Magistrates' Court has referred the case to Bristol Crown Court.
Magistrate Dr Jennifer Gunning, chair of the bench at the court, said she felt her sentencing powers were not sufficient.
Dr Gunning said: "Guidance was available for more than 10 years, but this was blatantly not followed (by the hospital).
"The RUH management was inadequate. Mr Eyles died as a result of those failings and many other vulnerable patients were put at risk.
"We believe this to be so serious that our sentencing powers are not sufficient."
The court heard how the Health and Safety Executive (HSE) said a risk assessment did not identify potential dead legs in pipes where water can stagnate.
It also heard inspections of water temperatures and shower heads were not done regularly enough and lids on water tanks were not fitted properly, allowing insects to crawl in.
The HSE said even when money was eventually earmarked to improve the system it was withdrawn to be spent elsewhere.
In a statement read out in court, Mr Eyles' wife Andrea said: "Daryl's death to all of us was a tragic occurrence which has changed the lives of our children and myself so very much.
"It was a tragedy which could have been prevented, if appropriate measures had been taken, by the authorities."
Mark Davies, chief executive of Bath RUH, said the trust accepted liability in October 2004.
"The RUH took the death very seriously and we have learned from the very sad case," he said.
Speaking outside court, Mr Eyles' mother Peggy welcomed the magistrate's comments.
"It was the result we had wanted. He was an exceptional son, father and husband," she said.
"It was a bitter pill to swallow, knowing we had lost Daryl in that way."