Volume 1: Findings and Conclusions
13. What went right and what went wrong?
Individual criticisms: redressing the balance

1245 It is inevitable that an Inquiry such as ours focuses on what went wrong. The main point of having the Inquiry is to find out what went wrong and to see what lessons can be learned from this. This can be harsh for individuals. Their shortcomings are put under the spotlight. The overall value of the contributions that they have made is lost from view. We do not wish our Report to produce this result. Yet we cannot set out in detail the workload over the years of each of those who has received - at one point or another - a criticism in our Report. We must make some general comments.

1246 The more senior posts in the civil service are seldom sinecures. Ministerial office never is. We have limited our consideration of individual responsibility to those who occupied such positions. The shortcomings that we have criticised have not been the product of indolence; they have for the most part been mistakes made under pressure of work - pressure made the greater by the imposition on already busy lives of the considerable additional burdens of handling BSE.

1247 The day-to-day demands made by BSE on MAFF, and particularly on the State Veterinary Service, were considerable. By way simply of example, in the period with which we are concerned approximately 200,000 suspect cattle had to be inspected, slaughtered and autopsied by histopathology. The carcasses had to be collected and destroyed. Compensation had to be assessed and paid.

1248 Between 1988 and 1995 about 30 Statutory Instruments in Great Britain alone were brought into force making or amending Regulations dealing with BSE. Some of these involved a great deal of work, but more significantly they evidence the ongoing attention being focused on addressing the implications of BSE for both animal and human health during a period when it was considered unlikely that BSE was in fact a threat to humans. Thus the individual criticisms that we have made must be read in the context of participation in a positive response to BSE, which on the one hand brought the animal disease under control, and on the other resulted in the removal from human food and from medicines of a very high proportion of the material that might have had the capacity to infect.

1249 There are aspects of the response to BSE that stemmed from broader government policies, or from particular ways of handling the problem. Again, these may not be matters that give rise to individual criticism, but they may well highlight lessons for the future. For example, we have noted that Ministers often sought policy advice from SEAC during most of the period. A lesson we have drawn from this is that where the policy decision involves the balancing of considerations which fall outside the expertise of the committee, it will normally not be appropriate to ask the committee to advise which policy option to adopt. It is not our job to examine broad government policies, for example the deregulation initiative. Where relevant, we have examined their implications for the BSE story. For example, our consideration of the impact of the deregulation initiative for slaughterhouses is in Volume 6.

1250 Those who were most active in addressing the challenges of BSE are those who are most likely to have made mistakes. As was observed in the course of the Inquiry, 'if you do not put a foot forward you do not put a foot wrong'. In this context we think it right to single out for mention Mr Meldrum. Mr Meldrum was Chief Veterinary Officer in Great Britain for almost the whole of the period with which we are concerned. He involved himself personally in almost every aspect of the response to BSE. He placed himself at the front of the firing line so far as risk of criticism is concerned.

1251 Mr Meldrum impressed us as a particularly dedicated and hard-working civil servant. We are aware that many consider that he epitomises an approach on the part of MAFF that placed more weight on the interests of the farmer than on the safety of the consumer. We do not consider such an accusation to be fair.

1252 Mr Meldrum was at all times concerned that the livestock industry should not be damaged by a public reaction to BSE for which there was, in his opinion, no scientific justification. That is not an approach for which Mr Meldrum can be criticised. On the contrary, we consider that it was a proper approach for the Chief Veterinary Officer to adopt.

1253 In the BSE story there were a number of issues on which Mr Meldrum advanced the view that the possibility of risk to humans was too insignificant to warrant precautionary measures:

• Should offal of sheep be removed from human food?
• Should tripe and rennet from the abomasum be included in the SBO ban?
• Should tissues from calves under the age of 6 months be excluded from the SBO ban?
• Was MRM a risk to humans?

1254 We do not doubt that the views which Mr Meldrum advanced reflected his own beliefs.

1255 When Mr Meldrum had concerns about risks to humans, he acted on them. Thus:

• He recommended that there should be no exclusion from the SBO ban of intestines that had been procured to produce sausage skin.
• In 1990 he raised concerns in relation to peripheral nervous tissue going into MRM.
• In 1994 he raised the suggestion of banning recovery of MRM from the spinal column.

1256 We are satisfied that where Mr Meldrum perceived the possibility of a significant risk to human health he gave this precedence over consideration of the interests of the livestock industry.

1257 Pressures on busy people go some way to mitigate a number of other criticisms that we have made - for example, the failures to review the Southwood Report, and failures to give rigorous consideration to the form of the animal SBO ban.

1258 We have criticised the restrictions on dissemination of information about BSE in the early stages of the story, which were motivated in part by concern for the export market. We suspect that this may have reflected a culture of secrecy within MAFF, which Mr Gummer sought to end with his policy of openness. If those we have criticised were misguided, they were nonetheless acting in accordance with what they conceived to be the proper performance of their duties.

1259 For all these reasons, while we have identified a number of grounds for individual criticism, we suggest that any who have come to our Report hoping to find villains or scapegoats, should go away disappointed.