Lessons to be learned

Prof Hugh Pennington’s report into the Wales E.coli outbreak pointed to a lack of enforcement of hygiene regulations as one of the key factors in the incident, a bitter pill for the MHS to swallow. Ed Bedington reports

Professor Hugh Pennington’s report, following a year of inquiry into the South Wales E.coli outbreak, was much anticipated.

While the inquiry into the outbreak, which claimed the life of five-year-old Mason Jones and left scores of youngsters seriously ill, laid the majority of the blame squarely on the shoulders of William Tudor, the butcher at the heart of the outbreak, it also revealed serious failings on behalf of both the local authorities and the Meat Hygiene Service (MHS).

The MHS had “failed to perform effectively”, he said, pointing out that the likelihood of meat becoming contaminated with E.coli O157 at the abattoir that supplied Tudor would have been significantly reduced if the meat hygiene regulations had been followed and enforced. He added that, over “a prolonged period”, the MHS failed to effectively perform its overall enforcement function in relation to the abattoir, J E Tudor & Sons.

Despite knowledge of long-standing, repetitive failures, the abattoir was allowed to continue functioning, and the limited “light touch” enforcement action carried out was ineffective in ensuring the business was compliant with regulations, said Pennington. Most damning of all, however, were his comments that little seemed to have been learnt since the last major case of E.coli poisoning in Scotland in 1996. “I had hoped the lessons from the shocking events in Scotland in 1996 would stay in people’s minds. But some 10 years after leading a review into that outbreak, I have found myself looking at issues that are, disappointingly, all too familiar,” he said. A comparison between the two outbreaks showed that lessons had either not been learnt or had been forgotten, he added.

However, others in the industry expressed fears that the risk is still there now, a view backed by the family of Mason Jones. His mother, Sharon Mills, has called on local authorities to carry out an open and transparent investigation, and accused them of doing nothing but “talking” over the issue.

Norman Bagley, policy director with the Association of Independent Meat Suppliers, said: “Pennington makes it plain that between Wishaw and now, as far as he’s concerned, nothing has changed and that’s the biggest criticism. The MHS claims there has been a sea-change in management since the outbreak, but nothing has changed in the key area of them auditing themselves that makes a further outbreak less likely.

“The audit function must be removed from the MHS and a top-class team of veterinary auditors should be out there, doing little else and reporting directly in to the Food Standards Agency (FSA).”


In his report, Pennington made 20 recommendations, urging the industry to get to grips with food safety. Included among these was the recommendation that the FSA should remove confusion about avoiding cross-contamination and that it and other authorities should keep its option of “light touch” enforcement under review. (For full details on all recommendations, visit http://tinyurl.com/dbhbjf.)

The overriding outcome of the inquiry is that the regulation in place was sufficient; it was a failure of enforcement, combined with the deceit of the operator involved. Stuart Roberts, director of the British Meat Processors Association, said the situation which led to the outbreak should not have happened. “Failures of this nature are absolutely unacceptable. Simple things, such as cleaning and separating of cooked and raw are so fundamental, there should never be an excuse for getting it wrong.”

He said the criticism of the MHS was interesting: “The fact they failed to perform effectively is a big concern, because it’s crucial that food safety regulations are applied robustly and, tragically in this case, it didn’t happen. There were signals that processes were unsafe and it is unacceptable that authorities didn’t act on this.”

However, he played down the idea that self-regulation of the industry, a key long-term aim in the reform of the MHS, could leave the sector vulnerable to rogue operators. “It’s not about self-regulation meaning a softer touch. It’s about providing incentives for good performance and disincentives for negative performances. You might even end up with higher levels of enforcement within some operators, while those doing the job properly have fewer. At the moment, you end up penalising everyone as if they are the common denominator.”

Comment pending

The MHS and the FSA have said they are unable to comment on the report in detail until after the FSA board meeting in April.

A statement said: “The outbreak of E.coli in Wales in 2005 was a grave, but unusual event and the report of the independent Public Inquiry is valuable in understanding the chain of events that led to the outbreak. Everyone involved in the production and distribution of food has a role to play in ensuring food safety – from food producers to people in their homes. When rare outbreaks such as this occur, we must learn from them and further strengthen our systems.”

So, the industry must wait to hear what the MHS has to say, but the overall message is that it is vital the MHS takes on board the points made in the Pennington report. Roberts adds: “What’s crucial is that, in going through its reform, the MHS takes note of what Pennington has said. We need to make sure the mistakes the MHS made are not allowed to be made again.”