Volume 1: Findings and Conclusions
Executive Summary of the Report of the Inquiry
10. Occupational risk

• The possibility of contracting illness from contact with diseased animals or their tissues was a well-recognised occupational hazard. Workers in a wide range of occupations were potentially in contact with the tissues of BSE-infected cattle or with those of human victims. All of these occupations needed to be identified and to receive appropriate guidance about the precautions to reduce risk in respect of BSE and other TSEs.
• The delays in issuing advice to many of those concerned were unacceptable. Ultimately the main occupations at risk were identified and advice given. But a detailed chronology shows that it took over three years to complete the task of issuing simple warnings and basic advice to the most obvious high-risk trades.
• Work began in 1991 on guidance to those handling risk tissues in laboratories, hospitals and mortuaries. This took until September 1994 to be completed and issued. During that process a so-called 'fast track' professional letter took 14 months to prepare.
• In a different field, it took two-and-a-half years for advice to be issued to schools about risks from dissecting bovine eyeballs, though SEAC had asked in June 1990 for this to be done.
• The slow and erratic responses have indicated weaknesses in the standard system for handling a wide-ranging disease threat. The slow tempo of action, in part attributable to time spent on polishing and refining advice, stemmed from three factors:

- a failure in communication: the perception that the Southwood Report had indicated that the risk to humans from BSE was remote even without any further action, and a belief in the Health and Safety Executive (HSE) that action was being taken simply as a response to political and media pressures;
- the absence of a comprehensive review of pathways of transmission, which might have helped pinpoint where the issue of urgent advice could not wait;
- the decision to use the slow-paced existing consultative and drafting arrangements. This ought not to have been at the expense of prompt and straightforward interim warnings.

• The mistakes made in handling the occupational threats from BSE and the questions raised by them need to be carefully considered by the HSE.