Volume 1: Findings and Conclusions
1. Introduction
Our task

14 Our Terms of Reference require us:

To establish and review the history of the emergence and identification of BSE and variant CJD in the United Kingdom, and of the action taken in response to it up to 20 March 1996; to reach conclusions on the adequacy of that response, taking into account the state of knowledge at the time; and to report on these matters to the Minister of Agriculture, Fisheries and Food, the Secretary of State for Health and the Secretaries of State for Scotland, Wales and Northern Ireland.

15 Establishing and reviewing the history of the emergence of BSE and vCJD requires us to consider what occurred and why. Ascertaining what occurred is not straightforward, for we believe that the initial emergence of BSE was neither recorded nor appreciated, and the aid of the epidemiologist is needed to try to reconstruct what happened. Ascertaining why BSE and vCJD occurred is even more difficult. Many scientists around the world have been conducting research which bears on these questions. We have reviewed the results of this research to see what, at the time of writing our Report, can be said with a reasonable degree of confidence about the causes of BSE and vCJD. Many questions remain unanswered, but we believe that a number of widely held beliefs can be shown to be misconceptions.

16 Next we are required to establish and review the history of the response to the emergence of BSE and vCJD up to 20 March 1996. That was the day on which the Government announced the identification of a new variant of CJD and the conclusion that the cases were probably linked to exposure to BSE.

17 Establishing the response to the emergence of vCJD involves focusing on the few months leading up to 20 March 1996, during which the emergence of the disease was identified. In contrast, considering the action taken in response to the emergence of BSE has been a massive exercise. That action spanned a period of nearly ten years, starting in December 1986, when the emergence of a new disease in cattle was first suspected. The action involved the five Government Departments to which this Report is addressed, and on occasion other Departments, the Prime Minister and Cabinet. It involved local authorities throughout the United Kingdom charged with enforcing Regulations introduced to deal with BSE. It involved many other public bodies. It involved the rendering industry, the animal feed industry, the food industry, the pharmaceutical industry, and, of course, the farming industry. It involved the media. It involved the consumer and it involved the public.

18 When we speak of the consumer, we do not refer simply to those who ate beef. Products derived from the cow enter the food chain in a variety of guises. Tallow, the fat that is extracted by the rendering process, and gelatine, derived from the skin and bones of cattle, are used in a wide variety of foodstuffs. But the public was involved not merely as consumers of food. Bovine tissues and fluids are used in, or in the production of, medicinal products swallowed, injected or inoculated. They are used in the manufacture of surgical devices. They are incorporated in cosmetics. The emergence of BSE put in question the safety of each of these products. It also raised questions about the handling of waste derived from the manufacture of these products or directly from carcasses.

19 Not only have we been required to establish the action taken in response to the emergence of BSE, we have been asked to reach conclusions on the adequacy of the response, taking into account the state of knowledge at the time.

20 On the last day of the hearings we made the following observations about this part of our task:

The mechanisms by which policy decisions in Government are taken are complex. The important decisions involve preparation of information and advice to submit to a Minister, preparation that often involves a number of different officials. It is easy with hindsight to assert that an assumption should not have been made, or that a decision was inadequate, misguided or dilatory, or that there was a culpable failure to take action that the situation required. Public opinion, as events unfolded and reached crisis point, has made many such value judgements. Hardly a day goes by today without BSE being referred to in the media as epitomising maladministration, usually by the use of an epithet such as 'the BSE scandal'. We believe that we have been asked to consider the adequacy of the response to BSE so that these accusations, insofar as they relate to the period with which we are concerned, can receive a fair and dispassionate consideration.

21 As we shall shortly explain, in the years with which we are concerned, most of those responsible for responding to the challenge posed by BSE emerge with credit. But we have found that a number of aspects of the response to BSE were inadequate. There are lessons to be learned from the events of those years. We stress that identifying those lessons is more important than examining whether individuals should be criticised. Nevertheless, any description of inadequacies is bound to lead people to ask whether individuals are to be criticised. We have given anxious consideration to that question.

22 A finding that an action constituted an inadequate response to BSE does not necessarily mean that those responsible for the action should be criticised. An action may not have been adequate because it did not satisfactorily deal with things that were known about a problem at the time. But it would not be right to criticise an individual unless, given the knowledge of that particular individual, he or she should have acted differently.

23 We have approached our task on the premise that it ought to be possible to identify those with responsibility for the policy decisions, the actions to implement policy and the public communications that together made up the response to BSE.

24 In practice we have found allocation of individual responsibility difficult. In part this has been due to the passage of time, which has rendered individual recollection of material facts at least unreliable and frequently non-existent. In part this has been due to the complexity of the administrative processes. The willingness of those concerned to give us unrestricted access to internal papers, and to disclose these to the public, has enabled us and the media and the public to gain an insight into those processes which we believe to be unprecedented.

25 Our Inquiry has led us to consider in depth:

• the relationship between Ministers and officials;
• the relationship between Government Departments;
• the relationship between administrators and professionals within Departments;
• the relationship between public authorities and expert advisers; and
• the relationship between central and local government.

26 These relationships formed the structure within which major and minor decisions of policy came to be taken and implemented.

27 When considering individual responsibility we have had to bear in mind this structure. We have had to bear in mind the way in which the public administrative system works. Many decisions are the product of a team effort to which individuals have made different contributions. A faulty decision may be the result of an error of judgement in assessing the available scientific and other data, or it may have resulted from an individual failure or failures in the provision of data, or the provision of expert advice in relation to it.

28 We have had to bear in mind the constraints on advisers and decision-makers: constraints of law, constraints of resources, constraints of established government policy; and constraints of the legitimate interests of the agricultural and other industries as well as those of the consumer. The background volumes of our Report (which, as we explain below, have been prepared by Inquiry staff) contain information about these constraints.

29 We describe in Annex 1 to this volume the procedures that we adopted to ensure that this Inquiry was thorough, open and fair. These included particular procedures adopted in Phase 2 of the Inquiry for those areas which we considered might give rise to criticisms of individuals. Fairness demanded that individuals be given notice of any potential criticisms. Such a course had its costs. Those notified of potential criticisms, and the lawyers advising them, naturally devoted and diverted their efforts to attempting to meet the criticisms. This tended to focus attention on the areas to which the potential criticisms related, albeit that these were not necessarily the most important areas of the Inquiry, and thus to unbalance the process.

30 In considering the adequacy of the action of individuals we have kept in the forefront of our minds the dangers of hindsight. We have had regard to all the surrounding circumstances which have often explained and excused action which at first blush seemed open to criticism. We have had well in mind that in any situation there is likely to be a range of responses from the inspired to the unimaginative, all of which fall within the compass of a reasonable response. Only where, having regard to all the relevant circumstances, we have concluded that the response of an individual fell below the standard to be expected of a person holding his or her position, have we indicated that the individual was at fault. We have done so in clear language, stating that the individual 'should' or 'should not' have acted in a particular way. Where we have not made an express criticism, none should be implied. So as to avoid any misunderstanding, a list of individual criticisms can be found in Annex 2 to this volume, with cross-references to locations in the Report where the matter is discussed.

31 Consistently with this approach, when considering the actions of Government Ministers, we have not adopted the traditional convention whereby Ministers are held accountable for the actions of those in their Department, regardless of their personal level of involvement. As with other individuals, we have only criticised a Minister where we have concluded that, in all the circumstances, his or her response fell below the standard to be expected of that Minister in the light of his or her knowledge at the time.

32 This is not to say that we have proceeded on the basis that a Minister should never be criticised for following advice from officials. The fact that a Minister has followed this course cannot preclude the conclusion that he or she should have acted differently. It is, however, an important factor when considering whether a Minister should be criticised.

33 There are some instances where we have found the response inadequate, but have not identified failings on the part of specific individuals. These are usually cases where we have felt that, having regard to the constraints on our time and resources, an attempt to identify individual responsibility could not be justified. In all such instances we would emphasise that it would be wrong and unfair to infer fault on the part of any individual.