Volume 1: Findings and Conclusions
5. The animal health story
Monitoring
Renderers
Slaughterhouses
Knacker's yards and hunt kennels
'Cradle to grave' reviews
The truth emerges
The penny drops
The Meat Hygiene Service takes over and a new SBO stain is introduced
More shortcomings revealed
The new Order

419 Ministers looked to the State Veterinary Service (SVS) to monitor and alert them to any problems arising over the enforcement by local authorities of Regulations introduced by MAFF. The Food Act 1984 gave MAFF's veterinary inspectors the right to enter premises for this purpose. In 1989 Veterinary Officers (VOs) of the Veterinary Field Service (VFS) would make an annual visit to domestic slaughterhouses and a monthly visit to export-approved slaughterhouses to check that the various Regulations introduced by MAFF were being observed. These included the Meat Hygiene Regulations, the Meat Inspection Regulations, the MSSR and, after their introduction, the human SBO Regulations. Visits were also made by VOs to knacker's yards on an annual basis to check on observation of Regulations which applied there.

420 Reports of visits had to be submitted to MAFF on a prescribed Meat Hygiene Inspection (MH1) form, which had space for entries in respect of each of the applicable Regulations. When the 1990 Food Safety Act replaced the Food Act 1984, the right of entry of MAFF inspectors was not preserved. This did not inhibit them from making their regular visits. They would normally, however, arrange to visit in the company of the district council EHO responsible for supervising the enforcement of the Regulations in the slaughterhouse in question.

421 The Animal Health Act 1981 gave MAFF's veterinary inspectors the right to enter premises on suspicion that the Regulations under that Act were not being complied with. They also made regular visits to renderers to check for the presence of salmonella in accordance with the Protein Processing Order of 1981.

422 If VOs found that Regulations were not being complied with, it was their duty to inform the relevant local authority of this, giving guidance where necessary. The breach would be recorded on the MH1 form and would thus be drawn to the attention of MAFF officials at headquarters.

423 When the human SBO ban was introduced in November 1989, no specific instructions were given to the VFS as to monitoring compliance with its requirements. The human SBO Regulations were simply added to the list of those that had to be checked on the MH1 form. Nor, initially, were any special steps taken to monitor compliance with the animal SBO ban upon its introduction in September 1990. In October 1990, however, Mr Andrews, the MAFF Permanent Secretary, suggested that the Ministry should carry out checks at slaughterhouses and renderers so that Ministers could be assured that no SBO was getting into animal feed. Mr Meldrum was quick to take up the suggestion. He asked Mr Keith Baker to make arrangements for VOs of the Field Service to make special visits to slaughterhouses and to renderers to check on the handling of SBO. Mr Baker was the ACVO at the head of the Meat Hygiene Veterinary Section. It was strange, on the face of it, that he should be charged with the checking of an animal health measure. We would have expected this duty to fall to Mr Kevin Taylor, who was at the time head of the Notifiable Diseases Section and subsequently became ACVO responsible for animal health and welfare. The explanation was that the only Regulations that made express provision for the handling of SBO were the human SBO Regulations, and monitoring of these fell logically within the province of the VOs with special training in meat hygiene.

424 The system that was set up required the Divisional Veterinary Officers to submit monthly returns of visits made by the VOs in their divisions. These were collated on a regional basis and sent to an officer of the Meat Hygiene Veterinary Section at Tolworth - initially Mr Stephen Hutchins, followed in 1991 by Mr Alick Simmons, who was himself succeeded in 1995 by Mr Andrew Fleetwood (an officer in the Notifiable Diseases Section). That official prepared a summary giving the national picture. Although Mr Baker set up this system, he told us that responsibility for it subsequently shifted to Mr Iain Crawford, as head of the VFS; thereafter he continued to receive the summaries of the returns, but only as 'a matter of politeness' because they were prepared by one of his staff. Mr Crawford told us that he had responsibility for advising on the practical problems of implementing policy in the field, but no responsibility for making policy decisions or advising Ministers on policy.

425 Mrs Attridge, head of the Animal Health and Veterinary Group, explained to us that while administrators in her group had responsibility for monitoring and keeping the Regulations in relation to the animal SBO ban under review, her 'eyes and ears' on the ground were the field vets.

426 We found this a confusing picture. No one person appears to have been responsible for keeping the adequacy of the monitoring of the animal SBO ban under review. As the story progressed the initiatives for tightening the system tended to come from Mr Meldrum.

Renderers

427 Initial returns on visits to renderers in January 1991 led Mr Meldrum to direct that there should be a further round of visits the following month and that thereafter renderers should be visited every two months. These early returns indicated that SBO was being kept separate from other material and that renderers were making sure that it did not get mixed with the material being processed for animal feed. Unofficial reports were nonetheless received by MAFF of wrongdoing in some rendering plants. As Mr Lawrence remarked, 'short of catching them in the act it is a pretty hopeless task'.

428 The reports disclosed one area of particular concern. Renderers used common plant for processing offal which produced MBM for incorporation in animal feed, and for processing SBO, whose product had to be kept out of animal feed and disposed of as waste. Methods of cleaning or purging the production plant between one batch and the next varied widely, with some plants doing nothing at all. Once again Mr Meldrum intervened. In September 1991 he asked Mr Simmons to draw up procedures which would ensure that no cross-contamination occurred at rendering plants. In consultation with UKRA, Mr Simmons prepared a 'Code of Practice for the Handling of SBO at Rendering Plants', which was distributed in August 1992. This provided for precautions to prevent 'comminglement' of SBO with other material. MAFF officials had expressed concern at the use of the description 'cross-contamination'. The precautions included cleansing or purging of plants between batches.

429 Had it been appreciated when the animal SBO ban was introduced that a very small quantity of infective material might suffice to transmit BSE orally, ¹ we have no doubt that more urgent steps would have been taken to address the risk of cross-contamination in the course of rendering. As it was, the Code of Practice was a significant, if tardy, step in the right direction. But as we shall see, events in 1994 were to demonstrate that it was not enough.

430 Meanwhile, early in 1991, concerns had been raised about the disposal of protein produced from the rendering of SBO. SEAC had been consulted and advised that it was not satisfactory that it should be spread on fields as fertiliser. This led to the introduction of a statutory requirement that disposal of protein derived from SBO would have to be effected under licence, to be granted by MAFF. ² The licensing scheme required data to be kept of weights of SBO received by renderers and of the protein derived from it, which enabled a rudimentary check to be made that SBO had not gone astray at the renderers.

431 The VFS continued to make regular visits to renderers to monitor the practice of keeping SBO separate from other material. These gave no indication that the position was other than satisfactory.

Slaughterhouses

432 Mr Baker's instructions to Divisional Veterinary Officers about monitoring in November 1990 had focused on information to be provided about the handling of SBO at renderers. They included, however, a request that visits should be made to slaughterhouses in order to discover 'how slaughterhouses are handling specified offal'. The response to this request varied so much in format and detail that a further round of reports was called for. For these a pro forma was used which called for information about brain removal, staining and movement permits. No mention was made of ensuring separation between SBO and other material. Not until August 1992 were field staff expressly instructed that the 'essential feature in effective control' was ensuring that SBO was kept separate from other material in the slaughterhouse and during transportation to rendering plants.

433 Both before and after these instructions, the returns received in respect of visits to slaughterhouses gave a satisfactory picture of practices observed. There were occasional reports of failures to observe the requirements of the human SBO Regulations in relation to staining or movement permits, but not to an extent that was significant.

434 This picture contrasted with a series of unofficial reports to MAFF of evasion of the animal SBO ban. In November 1990 Mr Lawrence was invited by Mr Peter Carrigan, who had a substantial business operating the gut rooms of slaughterhouses under contract, to visit a gut room to see the operations involved and to consider whether existing controls were sufficient. Mr Carrigan was in no doubt that they were not, and that there was widespread evasion of the animal SBO ban. This visit led Mr Lawrence to question the adequacy of the monitoring that MAFF was providing and to suggest that weight checks should be carried out at slaughterhouses and renderers to verify that the weight of SBO reflected the number of animals slaughtered. This suggestion was considered to be impractical by the members of MAFF's Meat Hygiene Veterinary Section.

435 Mr Lawrence also suggested that a distinctive marker might be added to SBO, thus facilitating its identification in and after it had left the slaughterhouse. We had evidence that enquiries were made as to whether a cheap marker or stain could be developed for this purpose. They did not lead to a successful outcome, but we were not able to establish why this was.

436 Reports continued to come in from 'trade sources', some considered reliable, that the Regulations were being disregarded and that SBO was being consigned by slaughterhouses to renderers unstained. One source of such information was Prosper De Mulder, the major UK renderer. This was typical of the cooperation provided by this company to MAFF throughout the BSE story. The company operated to high standards and showed a consistent concern that the Regulations should be effectively implemented.

437 This concern was shared by Mr Meldrum. His reaction to reports of disregard of the Regulations was to seek to improve the rigour of the monitoring by the VFS. In August 1991 a Circular was issued to the field staff, informing them of reports of non-compliance with the Regulations and instructing them to carry out the occasional unannounced visit to slaughterhouses. Notwithstanding this, the reports from the VFS continued to portray a satisfactory picture so far as slaughterhouse practices were concerned.

Knacker's yards and hunt kennels

438 Officers of the VFS were instructed to make monthly visits to knacker's yards and hunt kennels; the frequency reflected the fact that these premises were subject to significantly less local authority supervision than slaughterhouses. The instructions given were that on these visits staff should review 'the procedures for the disposal of waste material generally and the specified offals in particular'. We are not, however, aware of any returns which dealt with the manner in which SBO was handled at knacker's yards and hunt kennels. The only relevant Regulations were the MSSR 1982. These required all knacker meat to be treated as unfit for human consumption. They provided for staining and for movement permits in relation to this, but made no specific provisions in relation to SBO. We believe that this is why the returns from the VFS made reference, on occasion, to non-compliance with the MSSR but no reference to the handling of SBO.

'Cradle to grave' reviews

439 A significant improvement in the monitoring of the handling of SBO was introduced on the initiative of Mr Simmons in April 1993. He recognised that individual reports on slaughterhouses and on renderers did not give headquarters a complete picture of SBO disposal. He issued a new pro forma, Form MH6. This extended the scope of the return to cover all aspects of SBO handling from the slaughterhouse, to the collection centre, to the renderer and to the final disposal of the protein derived from the rendering of the SBO. Confirmation was sought that SBO was separated from other material at all stages of its journey.

440 In 1993 three sets of the new 'cradle to grave' returns were summarised by Mr Simmons. They indicated that practices were almost universally satisfactory. Occasional infringements 'of a minor nature', such as failing to stain all SBO or failing to identify SBO lines, were drawn to the attention of the local authorities, which took remedial measures.

The truth emerges

441 Despite the rosy picture painted by the returns from the VFS, unofficial reports of disregard by slaughterhouses of the Regulations were becoming more frequent. These reports led Mr Crawford to issue instructions on 1 February 1994 that all renderers processing SBO should be visited during the month of February unannounced. Full and detailed reports were to be provided of what was found. In summarising these reports on 25 March, Mr Simmons observed that both at collection centres and at renderers the constituents of stored material awaiting processing had to be taken on trust. His conclusions were that a small but significant amount of the total SBO processed, as a result of being inadequately identified and separated from other material at the slaughterhouse, in transit or at the rendering plant, was finding its way into processed protein that was being incorporated in animal feed. It was to become apparent that the only error in Mr Simmons's conclusions was that the amount in question was not small.

442 Mr Simmons included in his report a number of recommendations for tightening controls on the handling of SBO. Mr Meldrum called two meetings of officials in the course of April to consider these. Some of the deficiencies in the animal SBO Regulations which we have described above were recognised - it seems for the first time - namely:

• The animal SBO ban did not require the separation of SBO from other material at all stages.
• The 1989 human SBO Regulations did not apply to knacker's yards.

443 Various measures were considered, including the requirement that SBO should be stained with a special dye.

444 On 3 May Mr Eddy, who had taken over as head of the Animal Health (Disease Control) Division in June 1993, chaired a meeting to consider the way ahead. He later wrote that at this meeting:

We spent a great deal of time clarifying in our own minds how the current arrangements work.

445 This was an exercise that should have been done in 1990 when the animal SBO ban was initially introduced. It was only from 1994 onwards that suitable legislative changes were prepared, including the requirement for a special dye for SBO, a requirement for SBO to be kept separate from non-SBO material, an approved system of movement permits, and a requirement that renderers handling SBO should be licensed.

The penny drops

446 It was at about this time that MAFF officials began to appreciate the true significance of breaches of the animal SBO ban. The numbers of BABs were soaring. In September 1993 the total had exceeded 4,000; by September 1994 it was to reach nearly 13,000. It was apparent that some had been born after the animal SBO ban had come into force. MAFF officials, including Mr Wilesmith, Mr Bradley and Mr Meldrum, were reaching the conclusion that the likely cause was double contamination:

1. contamination of MBM used for pig and poultry feed with SBO; and
2. contamination of cattle feed with pig and poultry feed.

447 This led Mr Meldrum to initiate a review of arrangements for the disposal of SBO. Subsequent developments were attributable in large measure to the commendable lead of Mr Meldrum.

448 In July 1994, because of pressure of work in Mr Eddy's division, Dr Richard Cawthorne, the head of the Animal Health (Zoonoses) Division, was asked to 'assume overall responsibility for progressing changes to the SBO controls and produce an action plan'. He was assisted by Mr Fleetwood, a Senior Veterinary Officer (SVO) in his division. Mr Fleetwood carried out an informal telephone survey of the quantities of SBO received by the major UK rendering plants. He compared this with the amount that ought to have been generated from the cattle being slaughtered. The weekly total was 400 tonnes short of the 1,200 tonnes which was his average estimate for the time of year. He concluded that the 'SBO controls were not working'.

449 Two further factors added to the gravity of the situation:

• In March 1994 preliminary results of a European study on the effect of the rendering process on inactivating BSE had demonstrated that the three systems that collectively provided most of the UK rendering capacity did not provide effective inactivation.
• In the summer of 1994 initial results of the CVL's attack rate experiment indicated that as little as 1 gram of infective material was capable of transmitting BSE orally to a cow. ³

The potential consequences of cross-contamination at the renderers and in the feedmill were all too plain.

450 On 10 August the new Minister of Agriculture, Mr William Waldegrave, received a submission proposing radical changes to the animal SBO ban (along with changes to the human SBO ban). In agreeing that they should go to consultation, the Minister expressed concern that 'the controls should be made as simple as possible'. A lengthy consultation period then ensued, which resulted in the introduction of new provisions after the Meat Hygiene Service had replaced the local authorities in the slaughterhouses.

The Meat Hygiene Service takes over and a new SBO stain is introduced

451 On 1 April 1995 the Meat Hygiene Service (MHS) was launched as an Executive Agency of MAFF. It took over from local authorities responsibility for meat inspection and enforcement of the legislation relating to meat hygiene and SBO controls in slaughterhouses and head-boning plants. At the same time, Regulations were introduced which required SBO to be stained with a new distinctive food colour, Patent Blue V, instead of the previous black stain, which was used for other unfit meat. ⁴ This new stain had been identified as suitable the previous autumn, following instructions given by Mr Meldrum.

More shortcomings revealed

452 Most of those who had worked in slaughterhouses for local authorities as Meat Inspectors, EHOs or OVSs transferred their employment to the MHS. With the MHS in place it was possible for both the MHS and the VFS to carry out rigorous monitoring of the standards of enforcement of the Regulations applied by the staff that the MHS had inherited. It quickly became apparent that there were widespread failures to dye SBO with the new dye, or indeed with the old one. Mr Peter Hewson, a senior official in the Meat Hygiene Veterinary Section, commented in a minute:

It is clear to us that the local authorities were not implementing the staining requirements of the SBO regulations with the diligence we would have expected.

453 In the first three weeks of June, under the leadership of Mr Fleetwood, the VFS carried out a period of national surveillance, in the course of which every slaughterhouse known to handle bovine material received an unannounced visit on which a thorough inspection was carried out. Mr Fleetwood summarised the result:

The overall impression of this snapshot view of the industry is that there is widespread and flagrant infringement of the regulations requiring staining of SBO. Insofar as this may reflect the general attitude of the industry to controls on SBO, it is of concern. Although the problems with separation are less extensive, there are grounds for suspecting that the highest risk tissues (brain and spinal cord) have been mixed with other by-products and processed for animal consumption . . . a careless attitude to separation and disposal seems to be prevalent and it is probably leading to accidents during disposal. ⁵

454 It is right that we should emphasise here a point made by a number of MAFF witnesses. Responsibility for implementing the human SBO Regulations lay with the operators of the slaughterhouses. Responsibility for enforcing the Regulations rested fairly and squarely on the local authorities, not on MAFF. The legislation did not even provide for MAFF to exercise a monitoring role.

455 We have drawn attention to the fact that the human SBO Regulations did not require SBO to be kept separate from other unfit material. They did, however, require SBO to be stained, whether or not mixed with other unfit material. This requirement was frequently disregarded. Slaughterhouse operators were not fulfilling their statutory obligations and local authorities were not enforcing them.

456 We have suggested that one reason for this was that the Regulations were designed for the protection of human health, and there were no concerns that failure to stain might result in SBO getting into the human food chain. This may explain, but cannot excuse, breaches of statutory duty. There were many other reasons for these:

• Budgeting constraints meant that some local authorities did not employ sufficient staff to carry out slaughterhouse inspection duties satisfactorily. Nor was it easy to recruit staff. This was particularly difficult in the case of the OVSs - who should have been the most important members of the team. Veterinarians tended not to relish slaughterhouse duties and we had evidence that, when it was possible to recruit these, often from overseas, their quality was sometimes poor.
• There was often resentment on the part of slaughterhouse operators, Meat Inspectors or both at the imposition at the top of the inspection hierarchy of the OVS, whose need and function was considered to be open to question.
• There was a lack of effective line management. Meat Inspectors were often left to their own devices, without supervision, and tended to become 'almost part of the plant staff', getting involved in trimming and perhaps even dressing, rather than keeping themselves removed and recognising their roles as enforcement officers.
• Local authorities were often reluctant to be over-exacting in respect of slaughterhouses that provided local employment and a local service to farmers, but were operating on the margin of solvency.
• Under the Government's deregulation initiative, there was a culture of 'light touch' regulation. At the same time there was a media campaign which pilloried local authority enforcement officials as 'bureaucrats from hell' or 'little Hitlers'.

457 More than half the plants visited in June 1995 were not meeting the statutory requirements on staining, and 60 out of 435 plants were not separating SBO correctly from other material. Sixteen were not separating it at all. This was the lamentable state of affairs that confronted Mr Douglas Hogg when he replaced Mr Waldegrave as Minister of Agriculture on 5 July 1995.

The new Order

458 One of Mr Hogg's first actions was to approve the terms of the proposed new Order, ⁶ after having carefully discussed their implications with the Parliamentary Secretary, Mrs Angela Browning, and with his officials.

459 The Order was admirably comprehensive and yet satisfied Mr Waldegrave's request that it should be simple. In a single piece of legislation, enacted under the Animal Health Act 1981, it contained provisions aimed at protecting both human and animal health. Those aimed primarily at protecting animal health included the following:

• a ban on feeding SBO to animals;
• a ban on using SBO in the preparation of animal feed;
• a ban on selling SBO for feeding to animals or for use in the preparation of animal feed;
• a requirement that brain and eyes should not be removed from the head and that the head should be disposed of as SBO;
• a requirement that SBO should not come into contact with any other animal material in the slaughterhouse;
• a requirement that SBO be marked with Patent Blue V;
• a requirement that SBO be removed to an approved collection centre, rendering plant or incinerator;
• a requirement that SBO be kept separate from all other animal material in transit, at the collection centre and at the renderer;
• a requirement for weight-recording and record-keeping by all those generating or disposing of SBO;
• a requirement for dedicated SBO facilities at rendering plants.

The last requirement had proved controversial during consultation. It was Mr Meldrum who insisted on its inclusion. Renderers were granted a period of six months to introduce new dedicated lines. The new Order came into force on 15 August 1995.

460 Meanwhile the VFS had carried out two further rounds of intensive unannounced visits, and the MHS management introduced training and awareness-raising for the staff that they had inherited to rectify the shortcomings that had been disclosed.

461 On 29 September Mr Fleetwood was able to report that the amount of SBO being processed had increased by over 100 per cent. A minor part of this increase was attributable to the fact that whole heads were now treated as SBO. The balance is indicative of the extent of the previous evasion of the Regulations. It suggests that the 33 1/3 per cent shortfall identified by Mr Fleetwood's telephone survey was probably not far short of the mark.

462 Although there had been a significant improvement by September, the VFS was still finding widespread failure to comply with the Regulations. Up to this point MAFF officials and Ministers had been comforted by the belief that the shortcomings discovered did not endanger human health. However, towards the end of October 1995 Mr Meldrum had the unenviable task of informing the Chief Medical Officer, Dr Kenneth Calman, of four instances where spinal cord had been found in carcasses that had been health stamped by Meat Inspectors. Mr Packer suggested that Mr Hogg should call in the slaughterhouse owners and 'read the riot act'.

463 Mr Hogg did just that. On 8 November he issued 'formal instructions' to Mr Johnston McNeill, Chief Executive of the MHS, calling upon him to 'make every effort to secure 100% compliance' with the Regulations. This was an extreme step for a Minister to take in relation to an Executive Agency.

464 On the following day, Mr Hogg called in slaughterhouse operators and read the riot act. He told them that he would only be satisfied with 100 per cent compliance with the rules. This ambitious goal was not achieved, but the concerted efforts of the slaughterhouse operators, the MHS and the VFS produced impressive results. Whereas in October the VFS visits had disclosed that 31 per cent of slaughterhouses had failed to comply with the Regulations in one respect or another, by November this proportion had dropped to 13 per cent. By the beginning of January, Mr Fleetwood was able to report that:

Very few problems are now being recorded other than a few lingering defects in staining and record keeping.

Of 344 visits made, only 5 per cent were recorded as unsatisfactory.

465 Knacker's yards and hunt kennels were included in the enforcement campaign. Mrs Browning met with their representatives to emphasise the need for improvement. Once again a remarkable improvement was produced. In one month alone, the proportion of visits to these premises which proved unsatisfactory dropped from 65 to 29 per cent.

466 By the end of 1995 MAFF had published a list of head-boning plants, incinerators and collection centres which had been inspected and which were approved under the 1995 Order to receive SBO. Renderers proceeded to upgrade their plant in order to provide dedicated lines for processing SBO as required by the Order. In some cases, short extensions of the six-month deadline had to be granted. On 13 March 1996 MAFF published a list of renderers approved to handle SBO together with a further list of head-boning plants, incinerators and collection centres.

467 Thus, by the end of the period with which we are concerned, there was at last in place a sound set of Regulations, imposing an effective animal SBO ban which was being properly implemented and monitored. At this point the abrupt change in perception of the risk that BSE posed to humans led to the imposition of a blanket ban on feeding animal protein to animals. The animal SBO ban became history.