Report Published on Welsh Outbreak25th March 2009
Prof Hugh Pennington has published his report of the Public Inquiry into the major outbreak of E.coli O157 in South Wales in September 2005.
The outbreak was the largest of its type in Wales and the second largest in the UK. 157 cases were identified, mainly school children in 4 local authority areas in the South Wales valleys. It resulted in very serious illness for some people and, tragically, the death of 5 year old Mason Jones.
The food safety requirements that were in place at the time of the Outbreak had been reformed in the years before it. Butchers' Licensing had been introduced as a result of the 1996 Outbreak of E.coli O157 in Scotland, which makes the fact that the Welsh Outbreak occurred particularly shocking.
Extensive testing carried out during the Outbreak, showed that the strains of E.coli O157 in infected people were indistinguishable from those found on cooked meats recovered from schools, in a sample of raw meat recovered from John Tudor & Son (a catering butcher's business) and in samples of cattle faeces from a farm. Cattle from the farm were slaughtered at the abattoir of J.E. Tudor & Sons Ltd, which was one of John Tudor's suppliers.
The Outbreak occurred because of food hygiene failures at the premises of John Tudor & Son. The proprietor, William Tudor, failed to ensure that critical procedures, such as cleaning and the separation of raw and cooked meats, were carried out effectively. He also falsified certain records and lied to Environmental Health Officers (EHOs).
The inspections undertaken by EHOs from Bridgemend were made less effective by William Tudor's dishonesty. Even so, they did not assess or monitor the business's management of food safety as well as they could, or should, have done. Clues were missed. Those that were spotted were lost in the system because there was no way of alerting other EHOs to issues or concerns for subsequent inspections.
On the balance of probability, the E.coli O157 that caused the Outbreak came from meat supplied by J.E. Tudor & Sons Ltd. Over a prolonged period, the Meat Hygiene Service failed to perform effectively its overall enforcement function in relation to the Abattoir. Despite knowledge of longstanding, repetitive failures, the Abattoir was allowed to continue functioning without significant improvement and in breach of legislative requirements. As a result, the risks of unsafe food being produced and supplied into the food chain were considerably higher than they should have been.
The path to infection for the majority of cases in the Outbreak was contaminated cold cooked meat that had been supplied for school meals.
Schools were supplied with meats by John Tudor & Son under a contract with the Rhondda Cynon Taf, Bridgend, Caerphilly and Merthyr Tydfil County Borough Councils.
The arrangements for the joint contract were inadequate, with a particular lack of clear and agreed roles and responsibilities between the organisations and key individuals. In addition, the system for monitoring was not operated properly and the system for recording complaints was seriously flawed.
An Outbreak Control Team (OCT) led by the National Publich Health Service for Wales was formed as soon as the possibility of an outbreak was identified.
The OCT identified a common link between the cases at a very early stage. They reacted quickly, which led to the early removal of cooked meats from the food chain. It also resulted in some cooked meats infected with E.coli O157 being recovered from schools before they could be consumed. Prof Pennington's overall conclusion is that the Outbreak control was done well and but for the quality of the analysis and the control measures taken, the Outbreak would have been considerably more severe and prolonged.
Lessons from the shocking events in Scotland (Wishaw) in 1996 should have stayed in people's minds, but 10 years after leading a review into that outbreak, Prof Pennington found himself looking at issues that were, disappointingly, all too familiar. A comparison of the failures that led to the South Wales Outbreak with those in Scotland show that some lessons have either not been learned or perhaps been learned and forgotten over time.
Setting the context for his recommendations, Prof Pennington stated that the food safety regulations which were in place at the time of the Outbreak, particularly the application of the HACCP (Hazard Analysis & Critical Control Point) approach, were relatively modern. In his opinion, if implemented correctly, they were sufficient to prevent an outbreak. He made 24 recommendations (key ones mentioned below), which can be found in the full and summary reports at: https://wales.gov.uk/ecoliinquiry/report/;jsessionid=4njVJCSRnkBmXhyRnrWthhkQJJQh3p2h7HkQ4T6JRqjRlchpnntR!-1868201774?lang=en
It is vital that all food businesses get to grip with food safety management based very clearly on HACCP principles, ensuring it is a core part of the way they run their business. More needs to be done to ensure that food businesses have an effective system.
It is recommended that additional resources be made available to ensure that all food businesses in Wales understand and use the HACCP approach and have in place an effective food safety management system that is embedded in their working practice. Food businesses are responsible for producing safe food.
The majority of businesses co-operate fully with inspectors to ensure they comply with requirements, but that is not always the case. The recommendations, therefore, reflect the need to improve inspection practices and include unannounced visits and discussion with employees.
Issues and concerns must be logged so that they are not lost when inspections are undertaken by different officers. Such action will help build an intelligent picture over time of a business's track record on food hygiene practice and compliance.
As a general point, regulatory and enforcement bodies should keep the choice of "light touch" enforcement for individual businesses under constant review. "Light touch" enforcement based pureley on the size of a business is wrong. It should not be allowed simply to roll on without a suitable point being reached at which formal and robust enforcement action is taken. Authorities must come down hard on businesses that present serious risks to health and those that persistently fail to comply with food hygiene and food safety requirements.
The 4 authorities involved have made substantial changes to their procurement sytems and procedures since the Outbreak and as a result of issues that came to light during the Inquiry's oral hearings. The changes include provision for the independent audit of businesses supplying high-risk food. However, it is recommended that all businesses contracting with public bodies for the supply of high-risk foods such as raw and cooked meats must be subject to independent food hygiene audits.
The recommendations will take time to implement, some longer than others, and Prof Pennington asked the National Assembly for Wales to monitor and report progress on implementation.
The Inquiry was limited to 4 local authorities, but the issues raised are as relevant to the other 18 authorities in Wales. Therefore, all are asked to review their policies, procedures and systems against issues raised in the report. The Welsh Assembly Government and the Food Standards Agency, working with the local authorities and other interested parties, should co-ordinaate the reviews to ensure a uniform approach and standard of review. Local authorities should make public the results of the reviews and details of any action that needs to be taken. They should consider not only weaknesses and failures identified in the report, but also what worked well.
Mindful of the need for further development and to ensure lessons learned are not forgotten, it is recommended that a substantial review of food hygiene enforecement in Wales should take place in approximately 5 years time. The review, which should not be a public enquiry, should help to maintain consistently high standards in the delivery of what are important public services. Most importantly, it will help ensure that the lessons to emerge from the Outbreak are not forgotten.
It is owed to the memory of Mason Jones to learn the lessons from this Outbreak and to remember them.
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