Volume 1: Findings and Conclusions
5. The animal health story
Why did it take so long?

472 In July 1995 Mr Packer commented in a minute to Ministers:

The unsatisfactory treatment of specified bovine offal in slaughterhouses reflects an unfortunate state of affairs which has presumably existed for many years. We must expect questions on why we allowed the situation to persist for so long.

473 We asked many witnesses why it was that the VFS did not identify the shortcomings in slaughterhouses earlier than 1994. Most had no answer to make, other than that the shortcomings that were revealed in 1995 were a recent development. This suggestion we reject. We are satisfied that they had persisted throughout.

474 Mr Fleetwood suggested that the problem was that, whether or not visits were made by formal appointment, slaughterhouses would have had advance warning of them. 'Unannounced' visits might have fallen into a pattern so that they were anticipated. Slaughterhouses would have taken steps to ensure that the right bins were in place and liberal quantities of stain being applied when MAFF veterinarians arrived.

475 These suggestions were speculative, but we think that there may be something in them. The VFS had no right of access to slaughterhouses. It would not have been easy simply to turn up to carry out an inspection without liaising with the local authority responsible for enforcement. The truly unannounced and unexpected visit may well have been a rarity.

476 Mr Fleetwood also suggested that animal health officers making the visits may have been fairly recent recruits to the VFS and 'easily browbeaten' by slaughterhouse managers. There may also be some truth in this suggestion. We believe, however, that before 1995 inspections by members of the VFS were much less rigorous than after the MHS had taken over. There were a number of reasons for this.

• Before 1994 the practical importance of the animal SBO ban was not appreciated. It appeared to be a precautionary measure to protect pigs and poultry that was probably unnecessary.
• The growing number of BABs and the result of the attack rate experiment led, in 1994, to the realisation that the animal SBO ban was a crucial element in the eradication of BSE.
• Before 1995 VFS visits were made 'on sufferance'. After 1995 they were made with the support of the MHS.
• Before 1995 the VFS visits were not targeted, for there were no Regulations requiring SBO to be kept separate from other unfit material. After 1995 there were specific statutory requirements to be monitored.

477 We consider that these are all factors which tend to explain why the shortcomings discovered in 1995 were not identified earlier by the VFS. MAFF officials were, however, receiving regular reports from unofficial sources that, contrary to the reports that were being made by the VFS, the animal SBO ban was being evaded. Are they to be criticised for not reacting more rigorously to these reports? Their reaction was steadily to step up the stringency of monitoring by the VFS until, finally, its reports confirmed the unofficial ones. Once again we have concluded that the failure to respond more positively was attributable to the failure to focus at the outset on the possibility that a very small quantity of infectious material might suffice to transmit BSE to cattle. As the years passed without cases of transmission of BSE to pigs and poultry, it must increasingly have seemed that the concerns which had given rise to the animal SBO ban were unfounded.

478 When in 1994 it was appreciated that shortcomings in the enforcement of the animal SBO ban were probably leading to the infection of cattle, Mr Bradley of the CVL concluded: 'We have to quickly and effectively re-assess and, if necessary, improve the policing of the controls both via MAFF and the Local authorities.' We believe that Mr Meldrum and his colleagues reached the same conclusion. Are they to be criticised for not reaching it sooner? Once again we have concluded that the failure to respond more positively was attributable to the original failure to explore the minimum amount that might infect and thus to focus at the outset on the danger of cross-contamination at the time of introduction of the ruminant feed ban. Given that failure, we do not consider that the manner in which MAFF officials performed their role of policing the animal SBO ban fell outside the range of acceptable responses to the facts as they appeared at the time.