Volume 1: Findings and Conclusions
8. Occupational risk
The issue of guidance to schools about dissecting bovine eyeballs
Chronology of guidance on bovine eyeball dissection

1044 We turn now to our other cautionary tale, this time involving a different part of Whitehall, the Department of Education and Science (DES), as it was then known. We deal with this topic at some length in vol. 6: Human Health, 1989-96, Chapter 9. The dissection of bovine eyeballs in biology lessons was one of the 'unusual pathways' for possible disease transmission - to teachers and pupils - and needed to be addressed, since the eye is closely associated with the brain structure. There was no basic disagreement among officials about that. What went wrong was that the relatively simple task of agreeing the text of a brief warning note about it turned into a two-year saga.

Chronology of guidance on bovine eyeball dissection

27 September 1989	MAFF discusses the issue in context of the SBO ban. Agreed effect would be minimal due to availability of sheep and pigs' eyes as alternatives for dissection. However, MAFF suggests amending Regulations to remove eyes before staining.
February 1990	Scottish Education Department consults and issues advice against using bovine eyeballs in Scottish schools.
20 February 1990	Dr Pickles raises issue of theoretical risk with MAFF and with Dr Diana Ernaelsteen, Medical Adviser to DES.
June 1990	SEAC advises that eyes of cattle more than 6 months old should not be used for dissection in schools.
July 1990	Dr Pickles informs Dr Ernaelsteen of SEAC advice and about the advice issued in Scotland. Dr Ernaelsteen to discuss within DES whether there is a need for promulgation of general advice within England.
July 1990	Welsh Office officials ask Dr Pickles whether guidance has been issued following SEAC advice. Dr Pickles refers them to Dr Ernaelsteen.
	DES Schools Branch 3 accepts responsibility for issuing guidance.
28 August 1990	First draft of submission to the Minister recommending the discontinuance of eyeball dissection.
21 September 1990	DES is reluctant to ban all bovine eyeball dissection and asks about ovine and pig eyeball dissection.
4 October 1990	Dr Ernaelsteen says ovine dissection is unsuitable, but pig or horse eyeball dissection and using bovine eyeballs from calves under 6 months old is acceptable.
5 October 1990	Mr Ron Jacobs (DES) undertakes to revise the first draft of submission to Ministers.
8 January 1991	DES prepares second draft submission to Ministers.
25 February 1991	Dr Ernaelsteen expresses concern to DES at delay in issuing advice.
19 April 1991	HMI queries whether advice issued yet.
25 April 1991	DES circulates revised draft of proposed advice to be cleared with Ministers.
9 May 1991	MAFF tells DES it is content with advice.
February 1992	Mr Jacobs leaves post and passes third and final draft to Mr M B Baker (DES).
March/April 1992	DES seeks cross-departmental views on guidance.
	MAFF queries why the procedure is taking so long but is content with advice. DH is content with advice.
	HSE doubts there are any problems but will contact DES soon.
16 April 1992	Mr J Creedy of HMI draws attention to articles in medical journals which state that risk is minuscule.
21 May 1992	Dr Ernaelsteen advises DES that guidance is not timely now.
June 1992	DES draft submission to the Minister stating it is wise not to take advice further. This is sent to Mr Baker.
	DH queries progress on advice.
August 1992	Welsh Office queries progress on advice.
7 September 1992	DH again queries progress on advice.
30 September 1992	Mr Baker states he is not willing to give this high priority due to Dr Ernaelsteen's advice.
14 October 1992	DH stresses that advice should be issued and that DES should not reject SEAC advice.
28 October 1992	DES responds stating that it will put submission to Ministers.
29 October 1992	DES sends a submission to the Minister of State on bovine eyeball dissection.
15-21 December 1992	Guidance issued and sent to education establishments in England.
7 January 1993	Guidance issued and sent to educational establishments in Wales.

1045 We know this episode has rightly been investigated by DES itself. Mr Baker had identified the issue as a matter for his branch, Schools Branch 3, in July 1990. We have concluded that steps should have been taken to avoid the delay that occurred from May 1991 to December 1992. As he himself acknowledged, responsibility for this delay fell in considerable measure to Mr Baker. Mr Jacobs, who had day-to-day responsibility for the issue within Mr Baker's branch until February 1992, also shared some of the responsibility. Mr Baker and, to a lesser degree, Mr Jacobs should have ensured that this matter was promptly and properly addressed. Mr Baker and Mr Jacobs faced a heavy workload of competing priorities at that time and this is something we have borne in mind.

1046 Unfortunately, it seemed to us that some delay was also caused by Dr Ernaelsteen's advice in May 1992 that guidance was no longer timely. Having commendably stood her ground up to then, we consider it regrettable that, in the absence of any new medical facts, Dr Ernaelsteen countenanced any further delay in issuing advice on stopping the practice of bovine eyeball dissection.

1047 The story seemed to us to offer salutary lessons. The people handling the matter were far from the scene of action on BSE. That was other Departments' business. Their own Minister was not involved. No framework of overall action was in place through which they were accountable. All in all there seemed to be no hurry. Meanwhile other work was more pressing. Safety of pupils and teachers was outside DES's normal remit and many people had to be consulted. As with all civil service documents, there was an urge to refine and polish wording. As time went by, the delay itself made the issue of guidance less appealing.

1048 Here as in other areas, excessively reassuring language about the risk from BSE sedated those who needed to act. Insofar as they had a perception of the situation, it was that the risk was remote. There was no strong sense of 'ownership' of the topic to overcome the difficulty of working across normal boundaries in unfamiliar territory. There was no overall frame of reference and accountability.