Volume 1: Findings and Conclusions
5. The animal health story
The operation of the statutory animal SBO ban
Before the ban
The human SBO Regulations
Enforcement
The voluntary animal SBO ban
The statutory animal SBO ban
Reliance on the voluntary animal SBO ban
Reliance on the human SBO ban
Knacker's yards and hunt kennels
SBO in transit

376 We noted earlier in this volume that the ruminant feed ban was not fully effective. One reason was that ruminant feed was contaminated by feed for pigs and poultry which contained bovine MBM from cattle incubating BSE. After September 1990, when the animal SBO ban came into force, this cross-contamination should not have mattered. Pig and poultry feed should not have contained any MBM derived from SBO. If a little of this got mixed with feed for cattle it should have caused no harm. This was not the reason for bringing in the animal SBO ban, but it should have been one of its effects.

377 The large number of BABs born after September 1990 shows that something went very wrong. Over 12,000 of these animals developed signs of BSE. A much greater number must have been infected with BSE, but were slaughtered and eaten before any signs developed. How were all those cattle infected? For the vast majority it was because their feed had been contaminated by pig and poultry feed infected with BSE. How was it that, despite the animal SBO ban, BSE was getting into pig and poultry feed? There is more than one answer. In Chapter 4 of vol 5:Animal Health, 1989-96 we identify two reasons which probably played a minor part:

• The Order excluded from animal feed the SBO that was banned from human consumption, but did not identify all the potentially infective tissues and products which might go into animal feed.
• SBO was not always cleanly removed from the parts of the carcass that went to be rendered for animal feed.

378 Each of these sources of potential infectivity is, we believe, of insignificance compared with the primary source of the infectivity that resulted in BABs. This was that SBO was mixed, both deliberately and by accident, with carcass remains that were rendered for animal feed.

379 There were always going to be problems with enforcing the animal SBO ban. The financial temptation to pass off SBO as offal fit for incorporation in animal feed was considerable. There were ample opportunities, in the slaughterhouse, in the collection centres and at the renderers to give way to this temptation. Admixture of SBO with other offal was hard to detect. Those practical problems were compounded by the form of the Regulations that were put in place. They were, quite simply, unenforceable. To explain why this was, we shall have to lead the reader through a complex regulatory maze.

Before the ban

380 In order to understand the working of the animal SBO ban, it is necessary to appreciate the scheme that operated for dealing with meat unfit for human consumption, including SBO, before the ban was introduced. This is a topic of complexity, dealt with in detail in Chapter 4 of Volume 5. Here we shall give a greatly simplified account.

381 Animals killed for human consumption had to be slaughtered in a licensed slaughterhouse. The parts of the animal which were not wanted or were not fit for human consumption would normally be removed to a renderer to produce tallow and MBM - the latter being used as an ingredient of animal feed.

382 Fallen stock or animals put down on the farm would normally be collected by a knacker's yard or hunt kennel. Although they could not be used for human food, a variety of other uses were made of these carcasses. Remnants, including heads and spinal columns, would commonly go to be rendered to produce tallow and MBM used for animal feed. This waste from knackers and hunt kennels provided about 10 per cent of all rendered material.

383 The Meat (Sterilisation and Staining) Regulations 1982 (MSSR) were complex provisions designed to ensure that unfit meat was not used for human food. In a slaughterhouse, Meat Inspectors had to identify unfit meat and ensure that it was separated from the meat that was to go for human consumption. They applied a health stamp on the meat that was going for human consumption. The unfit meat, if not sterilised on the premises, normally had to be stained black. It could only leave the slaughterhouse after the issue of a permit authorising its removal to an approved destination, which would normally be a renderer. A copy of the permit would have to accompany the unfit meat to its destination, before being returned to the local authority which had issued it, so that a check could be made that the unfit meat had not gone astray.

384 At the knacker's yard and hunt kennel, the MSSR provided that all meat had to be treated as unfit for human consumption. Any remnants sent off to be rendered had to be stained black and accompanied by a movement permit.

385 Limited exceptions were made to requirements to stain and to obtain movement permits in respect of some categories of unfit meat when they were placed in a container of green offal. Green offal consisted of the intestine and stomach of the cow, together with their contents. Green offal was unfit for human consumption and was readily identifiable, and so was not required to be stained. It acted as a passport for the unfit material that it cloaked.

The human SBO Regulations

386 The human SBO Regulations ¹ followed the scheme of the MSSR. Their broad effect was to add a parallel regime so that SBO had to be handled in a similar way to unfit meat under the MSSR. The Regulations applied only to slaughterhouses, as in knacker's yards and hunt kennels the whole of the carcass was already treated as unfit for humans and subject to the MSSR. SBO had to be stained in the same way as other unfit meat, stored separately from meat fit for human consumption and removed under cover of a movement permit. But there was no requirement that SBO should be kept separate from other unfit meat. On the contrary, the Regulations permitted SBO to go down the same chute as other unfit meat into the same container to be stained by a common stain and removed to the renderers as a single consignment.

387 There were one or two complications. Bovine intestine was an SBO. Under the 1982 MSSR, intestine and its contents, being a constituent of green offal, did not have to be stained even if found unfit for human consumption. Like other green offal, it could act as a passport for unfit meat in the same container, but that was not the case under the human SBO Regulations, under which bovine intestines were subject to the requirements of staining and movement permits. Nor did the Regulations explain how the system of movement permits should operate in respect of a mixed consignment of SBO and other unfit meat.

Enforcement

388 Regulations made under the Food Act 1984 and its successor the Food Safety Act 1990 fell to be enforced by the District Councils, of which there were 275, and by the unitary authorities in the Metropolitan and London Boroughs. ² Thus the 1982 MSSR and the human SBO Regulations fell to be enforced by this tier of local authorities, which were also responsible for enforcing the Meat Inspection and Meat Hygiene Regulations in slaughterhouses. Their Environmental Health Departments employed Authorised Meat Inspectors (AMIs) and Environmental Health Officers (EHOs), who were trained in meat inspection, to enforce all these Regulations. Some slaughterhouses were approved to produce meat for export. In these, Official Veterinary Surgeons (OVSs) engaged by the local authorities were responsible for overseeing the implementation of all hygiene and meat inspection Regulations. This became the rule in all slaughterhouses - domestic and export - following the introduction of the European Single Market on 1 January 1993.

389 Hygiene standards varied enormously in British slaughterhouses from the lamentable to the good, with the majority tending towards the former rather than the latter. This meant that the United Kingdom was unable to satisfy European standards and led, in 1995, to the transfer of meat hygiene enforcement functions in slaughterhouses from local authorities to central government, and to the establishment of a national Meat Hygiene Service, responsible to MAFF, to carry out those functions. Until that occurred there was a wide disparity, not merely in hygiene standards, but in the manner in which, and rigour with which, individual local authorities organised the fulfilment of their slaughterhouse enforcement obligations. In many slaughterhouses, staffing levels were such that Meat Inspectors had little time for anything except the vital function of ensuring that unfit meat did not go for human consumption. This was one reason why hygiene standards were so poor.

390 The MSSR 1982 were designed to ensure that unfit meat was not diverted into the human food chain. By 1989 in most slaughterhouses a routine had become well established under which the unfit material would be regularly collected by a local renderer to be turned into tallow and MBM for animal feed. Some was supposed to be stained and removed under a movement permit. Some travelled cloaked in green offal. Where such a routine was established, local authorities were permitted to authorise slaughterhouses to make out their own movement permits, and did so. In such circumstances, the Meat Inspectors and EHOs in many slaughterhouses devoted little time or effort to enforcing what seemed no more than formalities of movement permits and requirements as to staining and carrying unfit material in sealed and marked containers.

391 Once the container of offal left the slaughterhouse for the renderer, all supervision ceased. Often the container did not go direct to the renderer. Lorries would collect containers from a number of slaughterhouses, and sometimes they would be taken to collection centres, where offal from different slaughterhouses would be combined into larger consignments for onward carriage to the renderer. The MSSR 1982 envisaged that checks would be made on containers of unfit meat when in transit. So far as we are aware no such checks were ever made. The only checks carried out by District Councils were the reconciliation of movement permits once these were ultimately returned from the renderers, and the evidence was that this formality was, in practice, not an effective check.

392 If Meat Inspectors and EHOs had little time for enforcement of what may have seemed over-bureaucratic Regulations, the Government's deregulation initiative tended to convey, whether rightly or wrongly, the message that it was not desirable to be over-fastidious in insisting on compliance with the letter of the Regulations when there was no concern of substance that their object was not being achieved.

393 The evidence that has led us to these conclusions is set out in detail in Volumes 5 and 6. Some of it came to light when Mr Lawrence of MAFF was leading a team to investigate how enforcement of the Regulations worked in practice as part of the task of introducing the Meat Hygiene Service. Some of it came to light in 1994 and 1995, when very significant shortfalls were discovered in the quantities of SBO that were going for rendering. Some represents the testimony of individual witnesses given to the Inquiry.

394 One piece of evidence, which we found particularly significant, merits specific mention here. When the human SBO ban was introduced, it focused the attention of the Environmental Health Departments of the local authorities on the practical problems of the scheme established under the MSSR 1982. On 1 February 1990 Mr Mike Corbally of the Institution of Environmental Health Officers wrote to the Animal Health Division of MAFF with no less than 11 pages of enquiries and comments about the human SBO ban that the Institution had received. In particular, the requirements of the Regulations as to the containers in which unfit material was stored and transported and the formalities in relation to movement permits were proving difficult or impossible to comply with in practice. In 1994 MAFF was again to receive information that the system of movement permits was not working and 'had to rely on trust'.

The voluntary animal SBO ban

395 The MSSR and human SBO Regulations provided two parallel systems for handling all unfit meat. Renderers and the animal feed industry lost little time in introducing a practice of greater complexity. Under the voluntary animal SBO ban, described earlier in this chapter, feed merchants required renderers to supply MBM free of SBO, for incorporation into animal feed. The renderers, in their turn, required the slaughterhouses to segregate SBO from other offal. Other offal the renderers would pay for, as the raw material of MBM which they could sell on. SBO was unwanted waste. The renderers made a substantial charge for disposing of this.

396 The voluntary animal SBO ban was not complied with by all. Renderers found a market, albeit diminishing, of feed compounders who were happy to purchase, at a reduced price, MBM derived from SBO. Nor was there confidence that those who were purporting to comply with the voluntary ban were being scrupulous in doing so. It was difficult, if not impossible, to tell whether a container of decomposing offal contained an element of SBO. The financial temptation for slaughterhouses to pass off SBO as non-SBO material was considerable. Forced to trust the slaughterhouses, but with reservations about doing so, the renderers contracted with the feed merchants, not that they would supply MBM that was SBO-free, but that they would do their best to do so. Renderers, also, were under a temptation not to look too closely at the material that they were rendering to sell at a profit lest they should have to treat it as SBO to be disposed of at cost to themselves.

397 This, then, was the regime prevailing when the animal SBO ban was introduced.

The statutory animal SBO ban

398 The provisions in the Order bringing in the animal SBO ban were very short and simple. They made it an offence knowingly to sell or supply for feeding to animals or poultry, or to feed to any animals or poultry, any SBO. The same applied to any animal feedstuff known to contain SBO or where there was reason to suspect this. There was a fundamental problem with these provisions. Neither the feed compounder nor the farmer had any means of knowing whether animal protein incorporated in the feed had been derived from SBO. They were reliant on renderers to ensure that the MBM that they supplied was not derived from SBO. But the Order did not expressly make it an offence for renderers to manufacture MBM from SBO. It was arguable whether, on a proper construction of the Order, supplying such MBM to feed compounders was an offence. The renderer in his turn relied on the slaughterhouse, the knacker's yard and the hunt kennel to ensure that material supplied was separated into SBO and other offal. Yet the Order did not require this.

399 If those whose duty it was to comply with the animal SBO ban had no means of knowing whether ruminant protein incorporated into animal feed was derived from SBO, those responsible for enforcing the ban were in an even worse position. They had no means of proving that animal feed contained protein derived from SBO, let alone that those supplying the feed, or feeding it to animals, knew that it contained SBO. The Order was unenforceable.

400 In England and Wales, enforcement of Orders made under the Animal Health Act 1981 was the statutory responsibility of the County Councils and the Unitary Authorities in the Metropolitan and London Boroughs. Thus outside the Metropolitan and London Boroughs it was not the District Councils (responsible for the human SBO ban) but the County Councils that were responsible for the enforcement of the animal SBO ban. The County Councils sought to discharge that responsibility through the Trading Standards Officers employed by their Trading Standards Departments.

401 We had little evidence to suggest that Trading Standards Officers made any attempt to enforce the animal SBO ban, which is hardly surprising having regard to the practical problems of enforcement that we have described above. We did receive evidence of consideration being given by the Trading Standards Officers of one county, in conjunction with the State Veterinary Service and the local District Council, to taking action to address the practices of a particular renderer who allowed SBO to become mixed with offal that was going to be rendered to produce MBM for sale to feed compounders. It was concluded that there was no action that could be taken because:

1. There was no provision in the animal SBO Regulations which made it an offence for a renderer to mix SBO material with non-SBO material.
2. It was impossible to demonstrate that MBM which was being sold for incorporation into animal feed was derived in part from SBO materials.

402 Much later, in 1995, after defects in the Regulations had been identified, new provisions were introduced which were enforceable. ³ They included the following requirements:

• On removal from the carcass, whether in the slaughterhouse, the knacker's yard or elsewhere, SBO had to be kept separate from all other material.
• SBO had to be dyed with a distinctive blue stain.
• SBO had to be removed to approved premises for disposal.
• SBO had to be kept separate from all other material at all stages of its progress from the slaughterhouse to final disposal.
• Records had to be kept of receipt and onward despatch of SBO at each stage of its journey from the slaughterhouse to final disposal.

403 Why were the shortcomings in the animal SBO Regulations not identified at the time that those Regulations were introduced? Why did the Regulations not include requirements such as those introduced in 1995? Broadly, witnesses from MAFF gave two answers to these questions:

1. The Regulations were merely giving statutory force to the animal SBO ban that was already in place on a voluntary basis. This ban was being taken seriously and appeared to be operating satisfactorily.
2. A detailed statutory code for the handling of SBO already existed under the human SBO ban. Enforcement of this ban would have the additional benefit of ensuring that the animal SBO ban was complied with.

404 These views were implicit in this observation made by Mr Maslin in his submission inviting Mr Gummer to approve the draft Order:

Enforcement is the responsibility of the Local Authorities. They are already monitoring and enforcing the Bovine Offal (Prohibition) Regulations 1989. In practice, the specified offal is being separated from other material at the abattoir. It is collected and processed separately by renderers. As with the existing ruminant feed prohibition, the ban on its sale, supply and feeding will, to a large extent, be self-policing. In these circumstances there would be little or no resource implications for Local Authorities. ⁴

Reliance on the voluntary animal SBO ban

405 We have already drawn attention to the fact that the voluntary animal SBO ban was not universally applied. We have also drawn attention to the financial consequences of that ban, the motive that these gave for evasion and the doubts as to compliance - particularly in relation to the slaughterhouses. On the evidence that we received, there were no reasonable grounds for concluding that there was or would be satisfactory compliance with the animal SBO ban on a 'self-policing' basis. The voluntary animal SBO ban was not a satisfactory alternative to a statutory scheme that was capable of enforcement. We identify below the MAFF officials who should have appreciated this.

Reliance on the human SBO ban

406 Reliance on enforcement of the human SBO ban as a means of enforcing the animal SBO ban was misplaced for a number of reasons:

• For the reasons given above, Meat Inspectors, EHOs and OVSs were unlikely to devote much energy to enforcement of the technical requirements of staining and movement permits under the MSSR and the human SBO Regulations.
• Strict compliance with those Regulations was not practical and was not being insisted upon, as Mr Corbally's letter had demonstrated.
• It was of critical importance from the viewpoint of the animal SBO ban that SBO should be kept separate in the slaughterhouse and not mixed, whether by accident or design, with carcass remains that were going to be supplied to renderers as fit for incorporation in animal feed. There was, however, no statutory requirement in the human SBO Regulations that such separation should take place. There was thus no relevant Regulation for the District Council officials to enforce.
• Witnesses suggested that the AMIs and the EHOs employed by the District Councils would have been ready to help out their colleagues on the County Councils by ensuring that SBO was in fact handled separately from other unfit material. Although we have no doubt that many District Councils and County Councils cooperate closely, we were not persuaded that District Council officials, whose responsibilities were to protect human health, would be enthusiastic about enforcing practices that had relevance only to animal health, the more so when those practices were not required by any Regulations. In 1994 a MAFF official was to report of the District Councils:

It is clear that some Local Authorities see the legislation merely as an exercise in removal of SBO from carcasses and preventing its use for human foodstuffs.

We did not find that attitude surprising. It reflected precisely the area of legitimate concern for District Council officials.

• If the two tiers of councils were to cooperate in trying to make the animal SBO ban work, it was desirable that they should have been given some guidance by MAFF officials as to what was expected of them. No such guidance was given. They were simply sent a copy of the 1990 Order and asked to arrange a meeting if they wished to discuss its enforcement. No such request was received.

Knacker's yards and hunt kennels

407 So far we have been concentrating on slaughterhouses, for they were the major suppliers of raw material to the renderers. Turning to knacker's yards and hunt kennels, we find a particularly unsatisfactory state of affairs.

408 The definition of SBO in the animal SBO Order followed that of the human SBO Regulations. This defined SBO by reference to offal from animals 'slaughtered' in the UK. The ban thus did not apply to any offal from fallen stock - the major source of knacker meat. It is not clear to what extent knacker's yards and hunt kennels took advantage of this lacuna and continued to use SBO as a source of animal feed, for MAFF made it plain that the Order was intended to apply to these premises. This error in the Order was remedied by amendment in 1991. ⁵

409 Although the 1991 amendment of the animal SBO Order made it illegal to feed to animals SBO from fallen stock, or protein derived from this, there were no Regulations which required a renderer to separate SBO from other material. The handling of knacker meat was governed by the MSSR 1982, which treated all of it as unfit for human consumption. There was no statutory basis for insisting that knacker's yards or hunt kennels separate SBO from other material being sent to renderers. We are not aware of either County Councils or District Councils making any attempts to enforce the separation of SBO from other matter at knacker's yards or hunt kennels. Those renderers that were prepared to receive material from knackers for production of MBM - and they were a minority - insisted that it should be SBO-free. We are sceptical as to how rigorously the knacker's yards complied with that requirement.

SBO in transit

410 No Regulations required SBO to be kept separate from other offal when in transit to the renderers. There was scope for admixture, deliberate or accidental, when containers of SBO and non-SBO material were carried together on the back of the same vehicle and, more particularly, when stored together in collection centres. Neither District Councils nor County Councils considered it any part of their duties to check what was happening to SBO in transit.