Volume 1: Findings and Conclusions
6. Protecting human health
The final months
Mr Hogg's questions
SEAC's meetings on 5 January and 1 February 1996
The storm clouds gather
Rumbles of thunder
The storm breaks
Postscript
Contingency planning
What would contingency planning have achieved?

782 We come to the last section of this part of our narrative - the final months leading up to the Government's announcement that young victims of a new variant of CJD had probably caught BSE. In the final days leading up to 20 March 1996, there was frantic activity. In January and February the contemporary documents give no hint that anyone in MAFF or DH appreciated the storm that was gathering. Do they paint an accurate picture? Were MAFF and DH taken by surprise when scientists at the CJDSU identified a new variant of CJD and SEAC concluded that it was probably linked to BSE? Had they given any thought to how they might respond in that eventuality? Should they have done? Was the action taken in the final days an adequate response to the situation? If there was any delay in waking up to the fact that a crisis might be approaching, did it affect the outcome? These are some of the questions that we shall be considering in this section.

783 Before turning to these important matters, we propose to follow a sub-plot of less significance. In the last section, we looked at action being taken by the Government and by the MLC in an attempt to allay concerns about whether it was safe to eat beef. Further steps to achieve this object continued to be taken in 1996. We consider these both with a view to examining whether they were appropriate in the circumstances and for the light they throw on the extent to which those involved appreciated the storm that was about to break.

Mr Hogg's questions

784 In the previous section (paragraph 775) we saw that Mr Hogg decided that SEAC should be asked a number of questions. This was not because he wished to know the answers. It was in the hope that the answers would be suitable to publish in order to give reassurance to those who were worried about the safety of eating beef.

785 This was a venture of which the MLC approved. It also hoped to make use of SEAC's answers in its campaign to restore consumer confidence in beef. Dr Kimberlin, who was a member of SEAC, was also retained as a paid consultant to the MLC. Mr Colin Maclean sent Dr Kimberlin a list of model answers to SEAC's questions. He explained:

We agree that we need succinct answers to these questions and my colleagues in our PR company . . . have drafted the sort of answers they would like to see (although they cannot put words into SEAC's mouth!). However, this should give you some feel for what we would initially like before you face the questions in SEAC. Anything you can do to help get crisp answers would be a big help.

786 The model answers, as one might expect, all provided the maximum reassurance as to the safety of beef.

787 We do not think that Mr Maclean should have asked Dr Kimberlin to provide this assistance. It put him in a position where his interest in helping the MLC might reasonably have been perceived to conflict with his duties as a member of SEAC. Dr Kimberlin did not perceive that the request created a potential conflict of interest. He told us that when addressing the questions as a member of SEAC he was wearing his SEAC hat, not his MLC hat. He did not inform SEAC of the MLC's request when discussing the answers to the questions.

788 SEAC considered the questions when they met on 5 January 1996 and again on 1 February. The Committee members did not agree on all the answers and the exercise was never completed; it was overtaken by events in March. Dr Kimberlin suggested answers of the kind that the MLC wanted. One was virtually verbatim in the form of the suggested model answers. All were reassuring about the safety of beef. We do not suggest that these represented other than Dr Kimberlin's own opinions. Thus there was in fact no conflict between his duty to advise objectively as a member of SEAC and the interests of his client, the MLC. There was, nonetheless, the appearance of a conflict. Dr Kimberlin should have told the members of SEAC of the request that the MLC had made, so that no one would have been able to suggest at the time or subsequently that he had a hidden agenda.

789 Suggested answers to the questions from other members of SEAC were not succinct or unequivocal. They would have been quite unsuitable for use in support of a 'beef is safe' publicity campaign. We think that these members were not prepared to lend themselves to the exercise that Mr Hogg had planned. With hindsight we can see that it was not a desirable exercise. In the first place, it diverted SEAC from more important work which they might otherwise have been asked to do. In the second place, we consider that the appropriate role for SEAC was to provide advice to the Government, not to provide publicity material to bolster the beef market. In the third place, if SEAC had provided the sound bites which had been wanted, the public would have perceived them for what they were - publicity material - and SEAC's credibility would have been damaged.

790 Mr Hogg and his officials gave further consideration to how to support the beef market at a meeting in the middle of January. Mr Hogg concluded that MAFF's principal role was to put factual information into the public domain and that MAFF should not be involved with the MLC campaign. We think that this was a wise decision. MAFF set about preparing their own information pack and revising two booklets about BSE.

791 By the end of February MAFF had prepared a leaflet entitled 'British Beef and BSE: The Facts', which was intended for a wide distribution. On the front page it stated:

Two facts should be made absolutely clear at the outset:

Fact 1 There is currently no scientific evidence to indicate a link between BSE and CJD.

Fact 2 The independent expert committee set up to advise the Government on all aspects of BSE is satisfied that British beef is safe to eat.

792 Dr Wight, who was leading for DH on the medical aspects of BSE and CJD and attended SEAC's meetings as an observer, met with MAFF officials on 28 February. The next day she minuted Dr Metters, suggesting that there was 'some merit in the leaflet being issued jointly by both Departments'. Dr Metters did not agree. He replied:

. . . some statements are too definite and in time may be seen to be wrong. We should not follow MAFF's hyperbole of reassurance. We must leave DH Ministers and CMO in particular, an escape route if any of these categorical statements turns out to be WRONG.

793 Mr Richard Carden, Head of the Food Safety Directorate, told us that MAFF's publicity material went to Ministers 'on the precise day when the first report suggesting there was a new variant of CJD came through' and that it was overtaken by events.

794 The fact that at the end of February Dr Wight was in favour of DH collaborating with MAFF in putting out this reassuring material suggests that she had no inkling of the storm that was about to break. The same can be said of the MAFF officials who placed the material before their Ministers at the moment that the thunder began to rumble.

SEAC's meetings on 5 January and 1 February 1996

795 SEAC met on 5 January 1996. ¹ Dr Will updated members on the current state of CJD surveillance. He drew attention to the number of cases of CJD diagnosed in young people. Between 1970 and 1989 no one under 30 had contracted CJD in the UK. ² Since 1990 there had been four definite cases and one possible. Two of the cases had unusual pathology and Dr Will thought that there was a very high chance that they were genetic.

796 The minutes of the meeting, as finally agreed, recorded that:

Dr Will was not unduly concerned at the overall number of CJD suspect cases that had occurred in the under 30 age bracket. What he did find worrying was that all the cases had occurred over a very short period. Professor Collinge was extremely worried at the occurrence of this number of young cases in such a short period, which could suggest a link to BSE. He requested that a formal statistical analysis be carried out to assess this further. The Committee concluded that the situation demanded the continuation of intensive monitoring of CJD. ³

797 Following the meeting, Mr Eddy, SEAC secretariat, sent a full note of the entire proceedings to Mr Meldrum, who had asked for this. Mr Meldrum told us that he was already concerned about the cases of CJD in young people and that Mr Eddy's minute indicated that there was no additional reason for concern.

798 Dr Wight told us that it was her practice to circulate a minute of SEAC meetings only if they had raised something that was relevant to public health, or required action that the Department needed to take forward, which senior officers needed to be aware of. On this occasion she sent a minute to Dr (now Sir) Kenneth Calman, which recorded the cases of CJD in young persons and added:

Although this is a significant increase over the incidence in the UK in this age group during the preceding surveillance period, it is not without precedent worldwide.

799 This was an inadequate report of this important item of SEAC's business. Dr Wight's minute neither suggested that the figures were cause for concern nor disclosed that the head of the CJDSU considered them cause for concern. The cluster of young cases observed within such a short period were without precedent in the world, let alone in a single country, and there had been no such sporadic cases in the UK in the previous surveillance period. Dr Wight's statement that 'it is not without precedent worldwide' was misleading and encouraged false reassurance. When giving evidence, she commented that her statement had been 'not quite correct'. She had meant to say that cases in young persons were not without precedent worldwide. She added, 'I probably dashed this off too quickly.'

800 Insofar as Dr Wight made no mention of the concerns expressed by Dr Will and Professor Collinge, we do not believe that she appreciated the significance of what was said. We consider that she should have communicated Dr Will's concerns to the CMO. In the event, her minute went on to deal with recommendations in relation to research, and she appears to have thought that this was the most important item that arose at the meeting, so far as DH was concerned. Dr Wight's minute was copied to Dr Metters and Dr Eileen Rubery, her immediate superior, among others. It did not alert anyone to the fact that the young victims of CJD were cause for concern. We are not surprised.

801 SEAC met again on 1 February. Dr Will's concerns about the young cases of CJD had increased because they appeared to share both a novel pattern of clinical symptoms and a novel pathology, although it was still too soon to reach a concluded judgement about these. Dr Will informed SEAC of these developments. The minutes record that he:

reiterated that the crucial issue is not simply the young age or pathology of recent cases but the short time scale in which 5 cases in individuals under 30 years of age had occurred.

802 Dr Will told the Committee that his colleague, Dr James Ironside's, ⁴ view was that it was premature to decide that these cases were linked with BSE.

803 Professor Smith confirmed Professor Collinge's suggestion that these cases were very significant in statistical terms. Professor Pattison's concern about the cases in young people was minuted. Professor Collinge told us that he reiterated his concerns that this was likely to represent BSE transmission to humans. Dr Will told SEAC that he intended to publish two scientific papers, one being about the young cases of CJD.

804 Mr Eddy circulated a minute about the meeting to Mr Hogg, Mrs Browning, Mr Packer, Mr Carden and Mr Meldrum. We think that he should have included a clear warning of the concerns that had been expressed about the young cases and the possibility that they might prove to be linked to BSE. He did not do so. He referred to the papers to be published by Dr Will as likely to give rise to problems which were essentially presentational.

805 Dr Wight minuted Sir Kenneth Calman about the meeting, with copies to Dr Metters and Dr Rubery, among others. Once again her minute was inadequate in that it failed adequately to express the concerns of members of SEAC about the young cases. In describing the conclusions that might be drawn from these, she used language which suggested that there was, in reality, no likelihood of a link between BSE and a new variant of CJD. We are inclined to think that this was, in fact, Dr Wight's own understanding. That would explain her support for issuing reassuring publicity, which persisted until the end of the month. Although a careful reading of her minute of the February meeting should have alerted the reader to the fact that young victims were a cause for concern, Dr Wight should have put this beyond doubt by referring to the concerns expressed by Professor Pattison and Professor Collinge.

806 We observed at the start of this section that the contemporary documents gave no indication that either MAFF or DH was aware in February of the storm that was gathering. The evidence given to us by some of the witnesses painted a different picture. We propose to defer our analysis of this evidence until we have taken on the story that is supported by contemporary documents to its close.

The storm clouds gather

807 On 1 March Mr Eddy passed on to Mr Meldrum some disconcerting news that he had just received from Dr Wight. It was looking 'rather firmer' that the cases of CJD in young people represented the emergence of a new sub-population of the disease. Dr Wight had suggested a meeting between MAFF and DH officials and press officers to discuss how it should be handled. He had agreed with Dr Wight that it would be absolutely essential in handling the news to have some form of statement from SEAC as to the implications. He would keep Mr Meldrum posted on developments.

Rumbles of thunder

808 SEAC met on Friday 8 March. Dr Ironside gave a presentation showing that a subset of young people with CJD had been identified with a tendency to a long duration of illness and a unique neuropathology. The pathology differed from the rare young cases of CJD that had occurred abroad.

809 Later that day, Mr Mike Skinner ⁵ minuted Sir Kenneth Calman and Mr John Horam. ⁶ He informed them that SEAC had concluded that exposure to BSE in the 1980s was a likely explanation for the novel cases of CJD.

810 Sir Kenneth Calman received Mr Skinner's minute on Monday 11 March. After discussing the position with his colleagues he decided to call a meeting with MAFF. This took place on 13 March.

811 On 11 March some members of SEAC made a visit to a slaughterhouse. They saw SBO being properly removed, identified and treated, and decided that there was no need to recommend any additional precautionary measures at that stage.

812 On 12 March Mr Eddy minuted Mr Packer to tell him of SEAC's conclusions about the novel cases of CJD. Mr Packer told us that from that date the pace of events became frenetic as it became more apparent every day that they would shortly be at the centre of a major national crisis.

813 Mr Hogg told us that he learned of the approaching crisis when Mr Packer came to his room one evening and told him that SEAC was coming to the view that BSE was transmissible to humans. There was no record of this visit, but Mr Hogg believed that it must have been sometime after SEAC's meeting on 8 March.

814 On 13 March Sir Kenneth Calman and other DH officials met Mr Packer, Mr Meldrum and MAFF officials. Professor Pattison was also present. Mr Packer advised Professor Pattison that SEAC should consider what action it thought appropriate. If the Committee made a recommendation, the Government would be likely to follow it. He added that it did not follow from the worst case scenario that the current rules needed to be changed. In a minute to Mr Hogg the same day, Mr Packer said that some elements in SEAC were apparently thinking of recommending a ban on the consumption of beef from animals over two years old. He questioned whether the cost of such a measure would be proportionate to any reduction in risk. He added:

Nevertheless, on the pessimistic scenario worries about the economic consequences of SEAC recommendations would be academic. If SEAC and the CMO issue statements acknowledging the possibility of BSE/CJD transmission I am sure that the public and market reaction would be such that the political and economic effects would be a disaster of unparalleled magnitude so far as UK food scares are concerned. The consumption of beef would be likely to fall immediately to a small proportion of its former level.

815 In discussion on that day and the next, Mr Packer and Mr Hogg agreed that it was necessary to get clear advice from SEAC as to the facts and the steps which the Government should take. They also agreed that they should 'avoid seeking to influence in any way' the conclusions to which SEAC would come. On 14 March Mr Hogg wrote to Professor Pattison asking him to submit SEAC's advice as soon as he was in a position confidently to do so.

The storm breaks

816 SEAC held an emergency meeting on Saturday 16 March. Dr Will gave details of nine confirmed and three suspect cases of CJD in young patients. Three independent neuropathologists had confirmed that these cases formed 'a distinct entity unlike any previously seen CJD'. There was intense discussion of what, if any, additional precautionary measures should be put in place. So far as human health was concerned, options discussed included:

• a ban on cattle aged more than 30 months entering the human food chain; and
• a requirement that meat from animals over 30 months old should be completely deboned and their obvious nervous and lymphatic tissue removed.

817 The discussion was inconclusive, apart from agreement that SEAC should 'recommend that all steps should be taken to ensure that the current SBO ban be enforced completely rigorously'. Finally SEAC agreed on a statement to Ministers. This noted that it had proved impossible adequately to explain the cases of CJD in young people, and continued:

This is cause for great concern. On current data the most likely explanation at present is that these cases are linked to exposure to BSE before the introduction of the SBO ban in 1989.

818 Mr Carden told the Inquiry that SEAC's desire to give further thought to the need for new measures caused acute difficulty over the following three days. At meetings during this period, Mr Hogg, Mr Packer and officials explored with Professor Pattison what SEAC's likely recommendations might be, but it became clear that SEAC could not reach a final view until it had fully assessed all the options.

819 On Monday 18 March Mr Hogg discussed with his officials a plan of action that he had decided on. He suggested that there should be a ban on the sale of beef from animals over 30 months old (what became known as 'the Over Thirty Month scheme'), and a judicial inquiry into the Government's handling of BSE. Both Mr Packer and Mr Meldrum questioned whether the 30 months scheme was proportionate and cautioned against taking action ahead of advice from SEAC. Mr Hogg said that he was not prepared to rely on the SBO ban as the sole line of defence when the controls were not being implemented perfectly. He wanted 'belt and braces'. Furthermore he was minded to recall all beef products from the food chain. In the early afternoon Mr Hogg had a meeting with Professor Pattison, who said that SEAC would not be in a position to advise until after its next meeting, which was scheduled for 23/24 March. He expressed a personal view that Mr Hogg's proposal of a 30 months scheme was 'justifiable, logical and not irrational'.

820 Before his meeting with Professor Pattison, Mr Hogg had signed a letter to the Prime Minister, to be sent jointly by himself and Mr Dorrell. This explained what had occurred to date and said that a detailed analysis of what would need to be done would depend in part on SEAC's recommendations and the policy conclusions that would flow from them. Before Mr Major had seen this, Mr Hogg told Mr Michael Heseltine, the Deputy Prime Minister, about the information it contained. Mr Heseltine was plainly horrified. He asked about the implications of slaughtering the entire national herd, and interrupted a meeting that Mr Major was holding to draw his attention to the joint letter.

821 Later in the day Mr Hogg sent a second letter to the Prime Minister. This set out his proposal for the 30 month scheme. It raised the possibility of withdrawing all beef products from the food chain and proposed a judicial inquiry into the Government's reaction to BSE.

822 In the early evening Mr Hogg and Mr Dorrell met, accompanied by their officials. Mr Hogg told Mr Dorrell of his proposal for a ban on beef from animals over 30 months old and for a judicial inquiry. The implications for DH of SEAC's findings were discussed. These included investigations into the safety of products other than food which had bovine content, such as vaccines.

823 Late in the evening Mr Hogg, Mr Dorrell and other members of the Cabinet met the Prime Minister. It was decided to call a ministerial meeting the following day and invite the CMO, the CVO and Professor Pattison to give their advice.

824 At the ministerial meeting on the morning of Tuesday 19 March, Mr Hogg told us that his recommendations were comprehensively rejected by his colleagues and that he accepted the decision of the meeting, although he believed it to be mistaken. This rejection is not clearly apparent from the contemporary record of the meeting. What is clear is that Professor Pattison would not be drawn into giving specific advice in advance of SEAC's meeting, scheduled for the weekend. After lengthy discussion it was decided that further information from SEAC was necessary in order to enable the Government to make a statement that included something of substance. 'An early meeting of SEAC would therefore be encouraged.'

825 Encouragement resulted, by 4.00 in the afternoon, in the assembling of Professors Pattison, Almond, Smith and Collinge and Dr Will in London, and the establishment of telephone linkage with Mr Bradley and Dr Kimberlin in Paris, where they had been attending a meeting of the Office International des Epizooties. Different options were discussed at length. By late in the evening no conclusion had been reached, but the meeting had received a message that the Government needed advice by 1030 the next morning. The meeting adjourned until 0800 the next day.

826 On 20 March it became clear that the news about BSE had leaked. 'Official: Mad cow can kill you', announced the headline of The Mirror. Other newspapers also carried the story that the Government was to announce the possibility that BSE could be transmitted to humans.

827 SEAC reconvened at 0800. By 0930 the Committee had agreed a statement. After saying that 10 cases of CJD in young people had been identified, this continued:

On current data and in the absence of any credible alternative the most likely explanation at present is that these cases are linked to exposure to BSE before the introduction of the SBO ban in 1989.

CJD remains a rare disease and it is too early to predict how many further cases, if any, there will be of this new form.

The Committee went on to make the following recommendations:

a. that carcasses from cattle aged over 30 months must be deboned in licensed plants supervised by the Meat Hygiene Service and the trimmings must be classified as SBO.

b. prohibition on the use of mammalian meat and bonemeal in feed for Rall farm animals.

c. that HSE and ACDP, in consultation with SEAC, should urgently review their advice in the light of these findings.

d. that the Committee urgently consider what further research is necessary.

The Committee does not consider that these findings lead it to revise its advice on the safety of milk.

If the recommendations set out above are carried out the Committee concluded that the risk from eating beef is now likely to be extremely small.

828 The Cabinet met at 1045 to consider SEAC's statement and a statement that Sir Kenneth Calman had prepared. It was decided that SEAC's recommendations would be accepted in full. It was also agreed that both Mr Dorrell and Mr Hogg should make statements to the House of Commons.

829 That afternoon Mr Dorrell made the first statement to the House. He described the CJD Surveillance Unit's findings of a new variant of CJD in young people and SEAC's conclusion that the most likely explanation was that those cases were linked to exposure to BSE before the introduction of the SBO ban in 1989. He explained the recommendations that SEAC had made and said that the Government had accepted them in full and would implement them as soon as possible. He then turned to a question that Sir Kenneth Calman had raised that morning - the question of whether children were more at risk than adults of contracting CJD. He stated:

There is at present no evidence for age sensitivity and the scientific evidence for the risks of developing CJD in those who eat meat in childhood has not changed as a result of the new findings. However, parents will be concerned about the implications for their children, and I have asked the advisory committee to provide specific advice on that issue following its next meeting.

830 Mr Hogg followed with his statement. He confirmed that the Government had accepted SEAC's recommendation that carcasses from cattle over 30 months must be 'deboned in specially licensed plants supervised by the MHS, and that any trimmings would be kept out of both the human and the animal food chains. In addition, Mr Hogg explained that he had instructed that existing controls in slaughterhouses and other meat plants and in feedmills should be more rigorously enforced. He emphasised that if the public accepted 'the best opinion that we have' that beef and beef products could be eaten with confidence, then he believed there would be no damage to the British beef market.

Postscript

831 This brings the period with which this Inquiry is concerned to an end. We should, however, record that on 3 April 1996 Mr Hogg announced to Parliament that the 30 month scheme that he had favoured would be put in place rather than the deboning scheme that SEAC had recommended. The principal reason for this change of policy was that the deboning scheme did not suffice to allay the anxieties of the consumer. Furthermore, within 24 hours of the Government's announcement accepting SEAC's advice, supermarkets made it clear that they would not be willing to sell meat from animals aged more than 30 months. A further, though subsidiary, problem was that the capacity of deboning plants was not enough to provide for the deboning under official supervision of all beef. It may be that a further motivation for the change was that it might help to persuade the EU to reverse the ban, which it had just imposed, on all British beef.

832 We have asked ourselves whether these problems that confronted the Government in its choice of policy option could not and should not have been foreseen. This leads us to the question of the extent to which there was any contingency planning in the months leading up to 20 March.

Contingency planning

833 At the meeting of the MAFF Consumer Panel, set up by Mr Gummer, of 24 January 1996, MAFF tabled a paper which included details of the recent young victims of CJD. Dr Godfrey, a member of the Panel, wrote a response, dealing with what he accepted was the unlikely possibility that they might prove to have been infected by BSE. He commented:

If the tiny cluster is due to people having been infected, further cases are likely, perhaps many of them. It seems best for government to plan now for this highly improbable possibility. This should include: (a) taking statistical advice on what will be taken as significant evidence, leading to action; (b) what advice should be given to consumers. It should be the aim to get advice across to us before the predictable reactions to what would be major tragedy, but also a major news story; (c) what action should be taken, in this hypothetical situation, to make the beef that could be eaten by consumers in the future safe again. This would obviously cost a lot, and be technically difficult, but possible.

His observations made sound sense.

834 In his first witness statement to us, Mr Carden gave this account of the reaction within MAFF to Mr Eddy's minute of 6 February:

Those of us who received Mr Eddy's 6 February report were aware that we could be on the edge of a very far-reaching change in the picture we had of BSE. My recollection is that from then on until SEAC reached a concluded view on 20 March 1996, we felt in a state of high alert. We - I am referring to myself and the circle of people within Government to whom the news at that state was deliberately confined - paid extremely close attention to each new indication from the leading experts. But for more than a month the tentative indications from SEAC's 1 February meeting were all we had to go on. The hints of bad news remained tentative, and we lived in suspense.

835 In a subsequent statement, he added:

Dr Will's findings were the first firm indications that the balance of probability might be shifting in favour of BSE actually being transmissible to man (contrary to what had generally been believed in MAFF up till then), and that one suspected means of transmissibility - ingestion of beef - had suddenly gained ground over the others that had been attracting more attention in autumn 1995 . . .

I and my colleagues in MAFF devoted much time and energy in the first months of 1996 to watching every new indication of what was going on; we moved into a state of high alert as events unfolded, and discussed and evaluated each new development intensively; with MAFF and DH in very close touch both at official and ministerial level at all key stages.

836 This is precisely what we would have expected to have happened on receipt of Mr Eddy's minute. We have criticised Mr Eddy for not drawing attention in it to the concerns expressed by members of SEAC about the implications of the young victims of CJD. Despite this, we consider that the contents of his minute should have put those who read it on alert in the manner described by Mr Carden. It did not. Mr Carden's recollection of the reaction to Mr Eddy's minute is mistaken. Whatever impression Mr Eddy's minute made on those who read it, it did not lead any of them to take any action.

837 Despite the shortcomings in Mr Eddy's minute, on reading that minute Mr Hogg and Mrs Browning should have sought to discuss its implications with Mr Packer, Mr Carden and Mr Meldrum. Similarly, on reading that minute, those officials, after discussion among themselves, ought to have raised its implications with Mrs Browning and Mr Hogg. Each of these five individuals should have considered the action that might be required should the scientists advise that BSE had probably been transmitted to humans, and they should have recognised the need for MAFF and DH to address the implications in conjunction, for example by seeking the views of Sir Kenneth Calman and by discussion between Mr Hogg and Mr Dorrell. In the event Mr Eddy's minute seems to have been treated by all simply as information on matters that called neither for action nor for discussion.

838 Mr Hogg told us, on the basis not of recollection, but of reconstruction, that he believed that he must have developed his 30 month scheme over a period of months, and discussed it with Mr Packer and other officials. Mr Packer gave this evidence some faint support when speaking of dim recollections of discussions with Ministers and others on a 'what if' basis. We are satisfied that there were no such discussions about Mr Hogg's 30 months scheme. Mr Hogg did not decide on this until shortly before he presented it to his officials on 18 March. There was no discussion between Mr Hogg and his officials prior to 8 March as to the options that would need to be considered should it prove that BSE had been transmitted to humans.

839 The position was precisely the same in DH. Sir Kenneth Calman made it plain that he was not himself involved in any contingency planning or discussions before March 1996. He added:

After the meeting in February, clearly both the Department of Health and MAFF, particularly through Dr Rubery's Division, were and should have been looking at these issues; indeed, as MAFF were; and clearly Ministers would be informed, as they always are when things are changing.

840 Dr Rubery, Dr Wight's superior, told us that she was worried about the cases of CJD in young people. She spoke of having frequent meetings with Dr Roger Skinner, a Principal Medical Officer at DH, which reflected her and her Department's growing concern about them. She said that this concern was also reflected in 'many informal discussions with Dr Wight, Dr Skinner, Dr Metters, the CMO and the Permanent Secretary', although she could not recall any further details of these informal meetings. We are satisfied that Dr Rubery's recollection that such meetings took place in February is mistaken. DH was not on a state of alert about the implications of these cases prior to March. Mr Dorrell was not even notified of the findings reported to SEAC at its February meeting. Dr Metters gave us some additional written evidence after he had appeared in Phase 2 of the Inquiry, in which he spoke of discussing prevention, care and treatment options with the Permanent Secretary and with Sir Kenneth Calman in mid-February. We do not believe that these discussions can have taken place before March.

841 Mr Carden stated that MAFF and DH were in very close touch at both official and ministerial level at all key stages. We have found that there were no interdepartmental discussions about the possible implications of the findings of the CJDSU in either January or February. Indeed, the Departments do not seem to have started to work together to address these until the meeting called by Sir Kenneth Calman on 13 March. Even then Mr Hogg proceeded to decide on the response that he considered appropriate without reference to Mr Dorrell or Sir Kenneth Calman. When we asked him whether he should not have discussed the 30 month scheme with Mr Dorrell, he replied:

No, forgive me, the 30 month rule was down to me; that was my policy; it was something for which MAFF was answerable.

842 We have already expressed the view that MAFF officials and Ministers should have consulted Sir Kenneth Calman when they learned about the content of the SEAC meeting in February. Equally we consider that when Sir Kenneth and Dr Metters received Dr Wight's minute of that meeting, albeit that it was couched in sedative terms, they should have initiated discussions with MAFF officials to discuss the implications of the new evidence, and Sir Kenneth should have alerted Mr Dorrell.

843 What was the reason for the inertia on the part of both Departments prior to March? Mr Carden gave this answer when asked why there had not been contact between MAFF and DH after SEAC's meeting of 1 February:

I think that both Departments will have been looking to SEAC to bring forward a firmer scientific view.

844 It was not merely SEAC's scientific view that the two Departments were awaiting. By 1996 the practice had become firmly established of looking to SEAC to advise on policy decisions - to an extent that came close to delegating them to SEAC. Witnesses told us that as the Government would not be prepared to take a decision without the advice of SEAC, contingency planning was a waste of time until SEAC's advice had been received.

845 Waiting for SEAC was not a satisfactory alternative to examining policy options. The choice between those options did not turn simply on matters falling within SEAC's areas of expertise. Wider political considerations needed to be taken into account, and these could well have been identified and discussed, on a contingency basis, in February. Nor was there any reason why SEAC should not have been asked to consider the various options that might be adopted to reduce risk of transmission further, and comment on their efficacy.

What would contingency planning have achieved?

846 The major policy decision taken on 20 March proved almost immediately not to be viable. The deboning option was not acceptable to the market, nor was it practicable. This option was recommended by SEAC under enormous pressure and instantly adopted by the Government, with no time to consider its implications. Mr Hogg took the view that it was not safe to rely on the proper performance of slaughterhouse operations to guarantee the safety of food. He wanted belt and braces. The supermarkets took the same view. Had MAFF, with the assistance of SEAC, begun to consider the options in February on a contingency basis, it is at least possible that they would have anticipated the problems which resulted in the choice of the deboning option being reversed almost as soon as it was made.

847 When Mr Dorrell made his statement to Parliament, he was unable to answer an obvious question. Were children more susceptible than adults to BSE? All that he could say was that he had asked SEAC to advise on this. In the event SEAC advised that there was no reason to believe that children were particularly susceptible. Contingency planning should have led to the anticipation of that question. SEAC could have been requested to answer it. Had its advice been obtained before 20 March, parents could have been reassured rather than alarmed.

848 There is a more fundamental question. One body of opinion considers that the over 30 months scheme was an over-reaction and that the risk that BSE was shown to pose to humans would have been adequately addressed by SEAC's deboning recommendation. We have asked ourselves whether the announcement of 20 March would have come as less of a shock:

• if the communication of risk to the public had not suffered from the defects that we have described;
• if successive CMOs and SEAC had stated plainly that they had growing concerns that BSE might be transmissible and that some humans might have been infected before the various precautions were introduced; and
• if those officials who commented on risk had frankly stated that the cases of CJD in farmers and in young persons were cause for concern, rather than emphasising that it was safe to eat beef.

Would the public have accepted that SEAC's deboning recommendation was an adequate response, so that beef from cattle aged over 30 months, removed from the bone, could have continued to be sold and eaten?

849 We have no doubt that had the approach to risk communication been that suggested above, the announcement of 20 March would have been less of a shock, and the public would not have felt that they had been deceived about the risk posed by BSE. But we do not believe the outcome would have been different. In March 1996 it was not clear how and to what extent the ruminant feed ban and the animal SBO ban had cut the rate of infection in cattle. No one knew, or could reliably calculate, how many cattle subclinically infected with BSE were entering the food chain. The improvement in slaughterhouse standards of removal of SBO was not yet clear. We believe that the public would inevitably have shared Mr Hogg's reaction that belt and braces were needed. Even today, over four years on, when these matters can much more readily be evaluated, the Over Thirty Months Scheme remains in place.