Volume 5: Animal Health, 1989-96
4b. Implementation, enforcement and monitoring of the animal SBO ban: discussion
The failure to keep SBO separate
In the slaughterhouse

4.643 With hindsight one can see that it would have been better if the animal SBO ban had included regulations that prohibited sending SBO to any plant producing animal feed, or ingredients destined for animal feed. Indeed with hindsight it appears extraordinary that, having identified material as potentially lethal to animals, it should be sent to be processed to plants whose primary business was the manufacture of components of animal feed. We shall consider later the reasons why this course was followed. Given that SBO was to be processed by renderers who also produced MBM for animal feed, if SBO was to be kept out of the animal feed chain, the following steps were necessary:

1. SBO had to be kept separate and distinguishable from other offal unfit for human consumption upon removal from the carcass, during subsequent storage in the slaughterhouse, knacker's yard or hunt kennels, and at the stage when it left those premises.
2. This separation had to be maintained during transit to the renderer.
3. The renderer had to maintain the segregation and process the two categories of offal separately.
4. The solid product from rendering the SBO had to be disposed of by the renderer as waste. The solid product of the other unfit offal could be sold as MBM for incorporation in animal feed.

4.644 We propose to consider for each of these stages whether effective requirements were made or whether they were in practice adopted (including the regime for enforcement by local authorities and monitoring by MAFF). We do this with the benefit of hindsight, before examining whether individuals should have acted differently either when preparing for the introduction of the animal SBO ban or during the years when it was in operation.

In the slaughterhouse

4.645 The requirement in the slaughterhouse was that SBO should be kept separate and distinguishable not merely from meat destined for human consumption, but from other matter unfit for human consumption that was destined to be incorporated in animal feed. To what extent was this requirement, imposed by law, followed in the slaughterhouse? We examine this question at the stage of removal of SBO from the carcass (including subsequent storage) and at the stage when it left the slaughterhouse. We then turn to look at enforcement by local authorities and monitoring of that enforcement by MAFF.

The animal SBO ban

4.646 The material provisions of the Order introducing the animal SBO ban (The Bovine Spongiform Encephalopathy (No. 2) Amendment Order 1990) provided:

8 (3) No person shall knowingly sell or supply for feeding to animals or poultry any specified bovine offal or any feedingstuff which he knows or has reason to suspect contains specified bovine offal or animal protein which is derived from any specified bovine offal.

(4) Subject to paragraph (5) below, no person shall feed to an animal or poultry any specified bovine offal or any feedingstuff which he knows or has reason to suspect contains specified bovine offal or animal protein which is derived from any specified bovine offal. ¹

4.647 Article 8(4) is plainly addressed to farmers and others who feed animals. The natural meaning of article 8(3) suggests that it is addressed to those who sell or supply feedstuffs to those who feed animals. It is far from clear that any person occupying a more remote position in the animal feed chain could commit an offence under 8(3). It is at least arguable that a renderer who supplied a feed merchant with MBM that contained SBO was not supplying this 'for feeding to animals'. The renderer, it could be argued, was supplying the MBM 'for incorporation in animal feed', which was not the same thing.

4.648 More forcibly, it could be argued that a slaughterhouse which included SBO in 'clean' material that it supplied to a renderer was not supplying SBO 'for feeding to animals'.

4.649 The above considerations are reflected in the following passage in AHC 94/106, dealing with the wording of article 8(3) and (4) as reproduced in the Bovine Spongiform Encephalopathy Order 1991:

Although direct responsibility rests with the persons supplying feedstuffs and persons feeding animals, it is clear that persons handling, transporting and processing SBO have an indirect responsibility for ensuring that SBO is not mixed with other material directly or indirectly intended for animal feedstuffs. ²

4.650 The emphasis is ours. The responsibility described as 'indirect' was not one which was imposed by the Order. A problem with the animal SBO ban was that it did not impose legal responsibility for ensuring that SBO was not mixed with material directly or indirectly intended for animal feedstuffs.

4.651 Solicitors acting on behalf of Mr Meldrum made the following written submission to us:

The 1990 Order clearly stated the prohibition on the use of SBO material for feeding to animals and poultry (sections 8(3) and (4)). The objective of the legislation was to reduce, and if possible to prevent, the risk of exposure of any species to the BSE agent, although, of course, ruminants were protected by the ruminant protein ban. Whether or not it is expressly stated, it is axiomatic that enforcement of such legislative provisions would require separation of the prohibited SBO material from other material intended for animal feed. To do otherwise would be to fail to comply with the law.

4.652 We do not accept this submission. Regulations which impose criminal liability have to be construed strictly. They did not, by implication, impose the obligations which solicitors acting for Mr Meldrum suggested were axiomatic. The 1990 Order imposed no obligation on slaughterhouses to keep SBO separate and distinguishable from other offal.

4.653 These deficiencies in the 1990 Order were addressed when the animal and human SBO bans were consolidated in a single Order in 1995 (see paragraph 4.853 below).

Separation upon removal: the human SBO ban

4.654 Evidence to which we shall refer later indicates a general assumption that provisions of the 1989 Regulations which introduced the human SBO ban required SBO to be kept separate and distinguishable from other material. Some witnesses persisted in that view when they gave evidence to us. Thus Mr Lowson said that at the slaughterhouse:

. . . there was a well-established system with well-established requirements for enforcement and the requirement under the 1989 legislation for SBOs to be packaged and labelled distinctly from other condemned material, as I read the 1989 order. So you have there the basic requirement, which is that the stuff is separate at the point where it is extracted from the animal. ³

4.655 Mrs Brown accepted that SBO could be mixed with other material unfit for human consumption, but considered that the 1989 Regulations required:

. . . anything with SBO in it to be identified during storage at the slaughterhouse . . . They required the staining of the SBOs . . . ⁴

4.656 The manner in which meat that was unfit for human consumption, other than SBO, had to be handled in the slaughterhouse was governed by the 1982 MSSR. The human SBO ban imposed by the 1989 Regulations followed an almost identical scheme. The question of whether, when the two sets of Regulations are read together, they required SBO to remain separated from other unfit meat, or alternatively, required anything with SBO in it to be identified as such, requires consideration of the two sets of Regulations.

Separation upon removal under the 1982 MSSR

4.657 A detailed analysis of the provisions of the 1982 MSSR, including its legislative history, is at Annex A to this chapter. For the present purposes the following requirements of those regulations are material:

1. Unfit carcass meat and specified offal [hearts, kidneys, livers and lungs from animals with certain specified diseases] that was destined to be sent to renderers had to be stained.
2. Unfit green offal [stomachs and intestines and their contents] destined to be sent to renderers did not have to be stained.
3. Unfit offal, other than specified offal, destined to be sent to renderers had to be stained unless held in a container containing mainly green offal.
4. Meat which was unfit or not intended for human consumption had to be stored separately from meat fit for human consumption in a container bearing a notice 'to the effect that the meat held therein is not for human consumption'.

Separation upon removal under the 1989 Regulations

4.658 A detailed analysis of the provisions of the 1989 Regulations is at Annex A of this chapter. For present purposes the following requirements are material:

1. SBOs destined to be sent to a renderer had to be stained. ⁵ The stain in question was the same black stain that was required to be used under the 1982 MSSR in order to identify carcase meat and specified offal.
2. SBO had to be stored separately from meat fit for human consumption in a container bearing a notice 'to the effect that the specified bovine offal contained therein is not for human consumption'. ⁶

4.659 The 1989 Regulations thus treated SBO in precisely the same way as specified offal under the 1982 MSSR. Nothing in these Regulations required SBO to be separated from other unfit material. A single container could legitimately contain stained specified offal, stained SBO, unstained unfit meat and unstained green offal.

4.660 We note that Mr Fry's instructions to MAFF lawyers in respect of the drafting of the 1989 Order directed as follows:

The material in question may not be sold for human consumption, and we are requiring that in effect it be treated as if it were 'specified offal' within the terms of the Meat (Sterilisation and Staining) Regulations. We would expect therefore that these offals would be treated like condemned/rejected/detained material in the slaughterhouse, knacker's yard or elsewhere except as I have outlined above. With those exceptions, depending upon practices, etc, the material would be dropped in bins, or down chutes, with other material to be carried to a condemned room or skip where it would be stained and subsequently collected and transported to a processor, or other approved destination under cover of a movement permit. No record-keeping provisions are required. ⁷

4.661 The 1989 Regulations made one important change to the scheme under the 1982 MSSR. Intestines were SBO and thus bovine green offal consisting of intestines and their contents was required to be stained.

Conclusions on the separation of SBO in slaughterhouses after removal from the carcass

4.662 One thing is relatively clear. The 1989 Regulations did not require SBO to be kept separate from other unfit material, either in the slaughterhouse or at any stage thereafter. It follows that it was no part of the District Councils' enforcement duties to ensure that such separation occurred. The object of both the 1982 MSSR and the human SBO ban was to ensure that the material that each covered did not get into the human food chain. So far as those Regulations were concerned, there was no reason why the two should not be amalgamated and sent off together to be rendered.

4.663 The 1982 MSSR required unfit meat to be stored or transported in a container bearing:

. . . a notice of adequate size which is conspicuously visible and contains a distinct, legible and unambiguous statement to the effect that the meat held [or carried] therein is not for human consumption. ⁸

4.664 The 1989 Regulations had identical provisions, save that they stipulated that the notice should be:

. . . to the effect that the specified bovine offal held [or carried] therein is not for human consumption. ⁹

4.665 In both cases the emphasis is ours.

4.666 It seems to us that in either case a large notice on the container saying 'not for human consumption' would suffice to satisfy the Regulations, whether the container held unfit meat, SBO or both.

4.667 It follows that we disagree with Mrs Brown's reading of the Regulations as requiring anything with SBO in it to be identified during storage at the slaughterhouse.

4.668 Although the Regulations permitted, and we believe envisaged, that SBO would be amalgamated with other unfit material in the slaughterhouse, in principle this should not generally have occurred once the voluntary animal SBO ban was introduced. Contractual arrangements with renderers required SBO to be separated from other unfit material, so that in practice slaughterhouses held SBO in separate bins or containers (see paragraph 4.109). Any accidental or deliberate failure to observe strict separation did not, however, constitute a breach of the Regulations. As we have explained, we believe that substantial quantities of SBO were, in fact, passed off as material fit for inclusion in animal feed.

4.669 We refer to the picture painted by Mr Fleetwood of the approach of the industry to SBO, as discovered in 1995 (see paragraphs 4.485-4.487 above). Failure to stain SBO involved a breach of the Regulations. The more significant failures to separate SBO from other material did not.

Separation when leaving the slaughterhouse under the 1982 MSSR

4.670 The provisions of the 1982 MSSR relating to removal of material from the slaughterhouse were complex. Their object was to ensure that matter that was unfit for human consumption did not get, unsterilised, into the human food chain. The Regulations reflected the fact that large quantities of such matter would be transported to renderers and there rendered. This achieved the object of the exercise, for the rendering process amounted, by definition, to sterilisation and the solid products of the process would not be likely to be used for human consumption.

4.671 The Regulations set out to ensure that where unfit matter was removed from a slaughterhouse or a knacker's yard to a renderer it did not escape, en route, into the human food chain. The manner in which this was achieved depended upon the nature of the unfit matter, and involved a system of movement permits.

Green offal

4.672 Unfit green offal could be removed from a slaughterhouse to a renderer unstained and without a movement permit. This was because green offal was unlikely to be used for human consumption.

4.673 Unfit offal was defined as including 'separate pieces of fat'. So long as it was not specified offal, it could be removed from a slaughterhouse to a renderer unstained (i) under cover of a movement permit or (ii) without a movement permit if in a container, the contents of which consisted mainly of green offal.

Carcass meat and specified offal

4.674 Carcass meat was defined as 'the flesh of an animal . . . including heads . . . but excluding offal'. Specified offal was defined as 'hearts, kidneys, livers and lungs' from animals rejected as unfit by reason of certain specified disease. This material could be removed to a renderer from a slaughterhouse only if:

1. stained, and
2. under cover of a movement permit or in a container, the contents of which consisted mainly of green offal.

Permits

4.675 Movement permits were issued by the local authority. They were in quintuplicate and entries had to be made in five parts:

1. Part 1: Was completed by the local authority and gave the address of the consignor and the consignee.
2. Part 2: Was completed by the consignor and set out:
1. description of material
2. quantity of material
3. number of containers
4. size and type of containers
5. expected date of arrival.

It also set out particulars of the means of transport.
1. Part 3: Was completed by the consignee, certifying receipt of the material.
2. Part 4: Was to be completed should the material be delivered to someone other than the consignee.
3. Part 5: Was completed by the local authority in whose area the material was delivered, recording receipt of the form. This local authority then returned the form to the local authority which had issued it, which would then be able to do a paper check to confirm that the material covered by the permit had reached its destination.

4.676 Where a slaughterhouse or knacker's yard made regular deliveries to a renderer, the Regulations provided that the local authority could issue batches of permits in advance. These would then be filled in as and when needed by the slaughterhouse.

4.677 The renderers would normally collect material for rendering from the slaughterhouse. Sometimes a single lorry would collect material from a number of individual slaughterhouses. Sometimes material from a number of slaughterhouses would be amalgamated at a collection centre, before being on-carried to the renderer. In that event the Regulations required the permit system to operate in two stages. Permits would have to be issued for the deliveries from the individual slaughterhouses to the collection centre. Further permits would have to be issued for the transit from the collection centre to the renderer. The exception from the requirement for a permit in respect of matter travelling under a cloak of green offal did not apply.

4.678 Matter being transported to a renderer or to a collection centre was required to be contained in a vehicle, or in an impervious container, which was kept closed and locked or sealed, bearing a notice containing 'a distinct, legible and unambiguous statement to the effect that the meat carried therein is not for human consumption'.

Separation when leaving the slaughterhouse under the 1989 Regulations

4.679 SBO could be removed to a renderer only if stained and under cover of a movement permit. The provisions as to the issue of movement permits and the information to be set out in them were virtually identical to those of the 1982 MSSR.

4.680 The provisions as to transportation were also identical, save that they required the notice to contain a statement 'to the effect that the specified bovine offal carried therein is not for human consumption'.

4.681 The Regulations prescribed separate forms of movement permit for SBO. Not surprisingly, some confusion arose as to the appropriate procedure in relation to a container holding a mixture of SBO and other unfit material. This was not the only confusion generated by the 1989 Regulations.

4.682 On 1 February 1990 Mr Mike Corbally, who was concerned with Professional and Technical Services at the Institution of Environmental Health Officers (IEHO), wrote to the Animal Health Division of MAFF with no fewer than 11 pages of enquiries and comments about the human SBO ban that the Institution had received. Those relevant to this point of the discussion were as follows:

Without guidance, differing standards of enforcement were likely to arise, not only throughout the country but also in localised areas. Furthermore, certain aspects of the Regulations quickly proved to be illogical, taking little account of meat inspection procedures. Many Departments report that they turned to the Ministry for advice. However, they have received an answer of 'you are the enforcing authority, you interpret the Regulations and enforce them as per that interpretation'. While the professional training of EHOs, together with their knowledge of meat inspection, would certainly allow them to satisfactorily interpret and enforce legislation, lack of guidance invariably leads to differing interpretations. Given the public prominence of the Regulations both in the UK and Europe clear interpretative guidance should have been regarded as a fundamental part to the enforcement process. ¹⁰

The subject of storage and disposal of SBO and the issuing of movement permits has caused considerable confusion and presented many practical difficulties. The points most commonly raised are detailed below. In view of the close association between storage, transportation and the issuing of the permits, the comments have not been divided into the individual Regulations.

(i) Considerable difficulties are being experienced with respect to the storage and removal of SBO in compliance with the Regulations, e.g. provision of containers/vehicles which are closed, locked, sealed etc. Effectively, the requirements would appear to be impractical and unenforceable. In the absence of any guidance from the Ministry, and I understand this has been sought by many of the authorities, a number of practices have therefore evolved that, whilst maintaining public safety take into account the practicalities of meat inspection and disposal of offal:

1. In large slaughterhouses, where they are not processing or sterilising the SBO on site, the practice is to mix the SBO with other green offal from species other than bovine, as per arrangements currently available for the disposal of 'unfit meat' under the [1982 MSSR]. Under the [1982 MSSR], such unfit meat, which would normally require a movement permit, can travel without one.Three questions that arise therefore are: is the mixing of SBO with other green offal acceptable? Does the mixture of offal (which will be predominantly 'green') require a movement permit to be issued as stated by the [1989 Regulations]?
2. SBO is mixed with meat that is classified as 'unfit' under the [1982 MSSR] and disposed of as such. Again, questions posed are: Is it acceptable to mix the SBO in this way? Does the mixture require the issuing of two permits, one under the [1982 MSSR] and one under the [1989 Regulations]?
3. In many situations this mixture of offal is stored in large open skips, as are used by most large slaughterhouses before being sheeted over then transported to food processor under the authorisation of a Movement Permit. This clearly does not follow the letter of the law, but alternatives are considered impractical when sealed containers etc have to be provided which necessitate a separate collection.

Whilst the above practices do account for practical situations, the issuing of movement permits in situations where SBO is mixed with other offal means that it becomes extremely difficult, if not impossible, for those officers in the local authorities and in whose area material is delivered, to be able to evaluate that the quantity of specified offal delivered matches the quantity stated on the movement permits. Furthermore, the issuing of two sets of permits leads to administrative and resource implications. . . .

(ii) The alternative to the above is to demand that SBO is stored in separate, clearly labelled containers. Whilst in some circumstances it may be possible to subsequently transport the SBO in a manner whereby the receiving authority can check the accuracy of the movement permit details etc, in some circumstances there may be a collection of SBO from a number of slaughterhouses by a single vehicle (albeit sealed and lockable). The result would be the bulk movement of SBO by one vehicle with a number of movement permits, the details of which could not be quantified at the final destination. Such practices of a single vehicle being used to collect offal from a number of slaughterhouses would also occur in a situation described in (i) above, thereby resulting in still further impracticalities of enforcement.

(iii) Although some authorities operate systems such as described in (i) above, the Institution are aware that waste processors have requested abattoirs to separate all SBO, or a considerable increase in charge for collection would be levied, i.e. a system of separate containers etc would have to be operated. This could have severe financial implications for abattoirs. ¹¹

(vi) The quick introduction of the Regulations initially resulted in authorities utilising makeshift permits for the movement of SBO. In many instances permits for the movement of unfit meat made under the [1982 MSSR] were used. This caused considerable problems in the early stages. However, as authorities were supplied with correctly printed forms the result was a passage of different kinds of form relating to both similar and different offal. That is, SBO movement permits, [1982 MSSR] permits for SBO and [1982 MSSR] permits for unfit meat. When considering the points made in (i) above, this has caused particular confusion for those authorities who have specialist boning plants etc within their area. The necessity to provide additional movement permits for SBO is causing administrative difficulties with regard to the logistics involved, again, especially for those Environmental Health Departments responsible for premises receiving SBO from a number of other premises. Even where blocks of permits can be issued, the quantity of SBO being produced is resulting in considerable resources being directed at filling in forms and following up delays in the return of relevant sections. In practice we would question the efficiency of administrative controls which are proving difficult to operate. It has been suggested that it would be extremely difficult to prove an offence or perhaps more specifically at what point an offence took place in the event of the non-return of the final copy of the movement permit to the originating authority. This is in spite of the fact that under the Regulations there is a requirement for certain individuals to hold copies of completed permits at various stages of its movement. What the Regulations do not take account of is the ability for the permit to go astray, either unintentionally or because of some unscrupulous act. The conclusion appears to be that it would be extremely difficult to achieve a successful prosecution. ¹²

Many Environmental Health Departments have raised the question of the resource implications of these new Regulations, e.g. time spent on issuing and controlling movement permits. Although resource implications are normally an issue for the local authority associations, the Institution would make the following comment with respect to ensuring the safety of public health. There are instances where premises covered by these Regulations (such as smaller abattoirs and specialist boning plants) do not under normal circumstances receive permanent or daily EHO/OVS [Environmental Health Officer/Official Veterinary Surgeon] supervision. To provide this service, thereby ensuring the Regulations are being complied with and public health is being protected, local authorities are experiencing a significant resource implication. Where these resources are not available the public cannot be said to have been adequately protected. ¹³

In view of the practical difficulties that are being experienced, and the general feeling of unease in relation to the effectiveness of the legislation you may feel that a meeting between ourselves will be appropriate . . . ¹⁴

4.683 An unknown reader at MAFF endorsed the comment 'Ouch' on this letter.

4.684 The letter appears to have taken a little while to circulate. On 6 February Mr Meldrum minuted Mr Baker asking:

. . . would it not be wise to draft instructions to Local Authorities on the implementation of the BSE Sterilisation and Staining Regulations or are our current instructions quite clear? ¹⁵

4.685 Mr Baker's reply reported:

No problems have come to our attention in implementing the Regulations. ¹⁶

4.686 However, a meeting took place on 9 April 1990 between Mr Corbally and Mr Baker, Miss Jones, Mr Maslin and Ms Rimmington, at which answers were supplied to some of the questions raised in Mr Corbally's letter. The only relevant answer recorded in the minutes was as follows:

Storage/Transportation/Disposal

Specified bovine offal (SBO) can be stored in the same container as other unfit meat, but would require a movement permit whenever it was moved and whatever state it was in. It was apparent that operations were not clear on this point. The permit required under the Bovine Offal (Prohibition) Regulations 1989 would take precedence over that required by the [1982 MSSR], and only one permit would be necessary for each consignment. ¹⁷

4.687 The minute of the meeting with Mr Corbally on 9 April records, in relation to the interpretation of the Regulations:

The IEHO accepted, however, that definitive interpretation could only be provided by the courts and agreed that for detailed legal advice District Councils should be encouraged to consult their own lawyers and if necessary seek Counsel's opinion. ¹⁸

4.688 It also records, in relation to the topics of storage, transportation and disposal of SBO:

The IEHO expressed willingness to help draft or distribute any guidance which was felt necessary on these subjects. ¹⁹

4.689 The minute was circulated to, among others, Mrs Attridge and Mr Lawrence. This offer was repeated in a letter from Mr Corbally to Mr Baker on 18 April 1990. ²⁰

4.690 On 22 May 1990 MAFF held a meeting with the Association of County Councils, the Association of Metropolitan Authorities, the Association of District Councils and representatives of the slaughtering industry. Following the meeting, the three local authority associations were sent a four-page guidance note on the movement and disposal restrictions that applied to the specified offal. ²¹

4.691 This guidance focused on the requirement to dispose of unsterilised offal by movement to a permitted destination. It did not deal with the problems raised by Mr Corbally. Furthermore, under a heading 'Green Offal' the guidance note stated that this could be moved to a processor for sterilisation (eg, a renderer) unsterilised and unstained and without a movement permit. The note did not point out that this option was not open in relation to bovine green offal that included intestines. ²²

4.692 In a submission to us, the Chartered Institute of Environmental Health remarked of the meeting of 9 April that:

While some of the issues of concern were addressed, there were a significant number that were not. ²³

4.693 We agree. It seems to us that considerable areas of uncertainty as to the manner of operation of 1982 MSSR and the 1989 Regulations in combination were left unresolved, not least as to the status of green offal. Nor were there any ready answers to some of the practical problems that would arise in relation to transportation if the regulations were strictly applied.

Conclusions on separation when leaving the slaughterhouse

4.694 We noted earlier (see paragraph 4.693 above) that where SBO and other unfit meat were in the same container, MAFF took the view that a single permit under the 1989 Regulations would suffice. But while in theory the permit should identify that a load included SBO, the practice of issuing these in batches, to be completed by the consignors, was not consistent with the use of them for enforcement purposes. It seems to us that it must in many cases have been impossible to identify the material to which a movement permit related. We have, in any event, no evidence that any District Council considered it part of its enforcement duties to carry out spot checks of unfit material against movement permits when material left the slaughterhouse, let alone thereafter. It seems to us that all that movement permits may have achieved in practice was to enable a check to be made, after the event, that a container that had left a slaughterhouse had arrived at its destination. We had no evidence to suggest that movement permits were of any assistance to local authorities or to renderers in determining whether SBO was being presented as material fit for feeding to animals.

4.695 We note that in 1995 the Local Authorities Co-Ordinating body on food and Trading Standards (LACOTS), UKASTA and Prosper De Mulder all expressed concerns about the movement permit system and that Dr Cawthorne concluded that the system:

. . . is administratively complex and does not provide an effective check on the amounts of SBO removed at slaughterhouses and disposed of at rendering plants. ²⁴

4.696 While evidence in relation to the use of movement permits in Great Britain is sparse, a draft minute to Dr McCracken, Deputy Chief Veterinary Officer, Department of Agriculture for Northern Ireland (DANI), written in July 1994, gives an informative picture of the position in Northern Ireland:

A. Weaknesses in present system

1. Waste skips carrying SBO from slaughter plants/head boning rooms are not labelled to indicate this. (There is no legal requirement other than to label 'Unfit meat - not for human consumption' and this does not differentiate SBO from other animal waste.)

This would suggest that identification of a load would be dependent either on (i) the load being accompanied by suitable documentation (this does not happen in practice - see point 9 below) or (ii) the renderer scrutinising the contents prior to rendering to establish the identity of the skip contents (we cannot assume the renderer will do this).

2. Documentation to accompany movements of SBO is required by Regulation 12 of the Bovine Offal Prohibition Regulations. EHOs have developed the practice of leaving pre-signed movement permits under the Regulations with Plant Management for completion once the exact number (eg bovine heads) or weight of SBO becomes known. Although an 'audit' procedure exists where the permits are endorsed at point of destination by the receiver and returned to the issuing council, there is clearly a weakness since EHOs are generally not aware of the number of slaughterings and hence not in a position to verify the quantity of SBO which plant management enter on the permit in the first place. Nor are they necessarily in a position to know whether a permit has been issued with an individual load as required. This, added to the fact that SBO costs the plant £65 per tonne for disposal must provide incentive and opportunity for certain plants to send SBO out as other waste and so avoid paying the heavy disposal fee. ²⁵

7. The Bovine Offal Prohibition Regulations were introduced to protect public health. There would be no real suspicion at present that SBO is entering the human food chain (the specified tissues are certainly not human delicacies in NI!). As a result it is understandable that EHOs are not overly concerned about close monitoring of movement/disposal of SBO.

Consignments of animal waste leave fresh meat premises without documentation on a regular basis; this is the case with all classes of animal waste and SBO is unlikely to be an exception. Drivers of skip lorries are accustomed to collecting licences relating to previous loads upon subsequent collection occasions or at the end of the week. The licences may even be posted in retrospect to the renderer. ²⁶

4.697 It seems that the picture was not much different in other parts of the United Kingdom. Mr Shepherd, a Senior Executive Officer (SEO), employed by LACOTS, wrote as follows to Mr Lackenby on 7 October 1994:

The current movement permit system has inherent faults and is considered to have limitations as a means of public health protection. It is supposed to be a monitoring system in which a paper record of the movement of SBO is made and can then be checked at the originating premises. There are opportunities for fraudsters to fill in the details incorrectly or to divert part of a load during transport. Then at the next stage of the process there is usually a week's delay before the renderer's local authority receives a copy of the permit, during which time the material is processed. In any case, even if the local authority is present at the time of delivery, it is not possible to check that the quantities specified on the permit have actually arrived. At the final stage of the system, the local authority for the originating premises receives a document which is not necessarily accurate, relates to material which has probably already been consumed or used. They quite often do not receive any copy at all due to human administrative failures.

The system is administratively onerous particularly for those local authorities with large rendering plants in their areas; they have to employ staff purely for administering receipt and return of permits. In practice, the system of movement permits has to rely on trust. ²⁷

4.698 Mr Hibbett, who had been a Senior Environmental Health Officer (SEHO) with Peterborough City Council, told us that when the 1989 Regulations came into force, the provisions in relation to movement permits:

. . . involved one officer doing nothing else but chasing these around, making sure they went out, checking them, checking in particular the difficulty of actually getting them back from the authority where they had been sent to. ²⁸

4.699 He went on to describe the difficulty that was experienced in getting the formalities of movement permits taken seriously, having regard to the impression given by Government that BSE was not a matter of serious concern:

You were seeing Ministers on television saying one thing; and yet on the other hand we were going to abattoirs saying: 'Look, we need you to fill in, in careful detail, exactly what is happening, exactly how much, exactly where it is going to', trying to persuade the lorry driver that he must keep it carefully and not have it blow away when he was stepping in and out of his wagon. That was our frustration, I think, where we were in a position where we were trying to enforce a piece of legislation, where the people we were trying to enforce it on were getting differing impressions as to its importance, that BSE was not a problem. ²⁹

We were dealing with transporters who were not enthusiastic about it. We were having difficulty in emphasising to them how difficult it was and important it was to follow this complex procedure, they were reading their papers and getting a completely different picture. ³⁰

4.700 The movement permit system introduced in 1982 was complex and bureaucratic. Its aim was to ensure that unfit meat did not enter the human food chain, but was made innocuous by sterilisation. By 1989, up and down the country, there must have developed well established courses of dealing, under which slaughterhouses consigned the offal that was unfit, or not suitable, for human consumption, to renderers. It would not be surprising if the movement permit system had, by then, become no more than a formality so far as many local authorities were concerned.

4.701 The evidence that we have quoted above indicates that there were widespread failures to implement the movement permit system in accordance with the 1989 Regulations. Even where the formalities were properly observed, it seems to us that the system provided no adequate safeguard, when containers of offal were received by renderers, that it would be apparent whether or not they contained SBO.

Enforcement of the Regulations in slaughterhouses

4.702 We shall see in due course that MAFF officials were relying upon the staff of the District Councils who were responsible for enforcing the Regulations made under the Food Act 1984, replaced by the Food Safety Act 1990, to ensure that all SBO was kept separate from other unfit material in slaughterhouses. With hindsight it is plain that they did not do so - indeed Mr Meldrum submitted to us more than once that, having regard to what has since been learned of the standards of enforcement of the local authorities, until the Meat Hygiene Service (MHS) had taken over the slaughterhouse duties of the local authorities, there were no measures that MAFF could have taken which would have made a significant improvement in standards of enforcement of the animal SBO ban.

4.703 There were many reasons why the Meat Inspectors, the Environmental Health Officers (EHOs) and the Official Veterinary Surgeons (OVSs) employed by District Councils in slaughterhouses did not enforce a strict separation of SBO from other material unfit for human consumption.

Lack of obligation to separate SBO from other unfit material

4.704 We have explained above that there was no statutory obligation on slaughterhouse operatives to carry out this separation. The District Councils could not reasonably be expected to enforce Regulations which did not exist. This point is not, however, a complete explanation. The complexity of the Regulations was such that some officials at least were under the impression that separation of SBO from other matter was a statutory requirement.

4.705 Mr Hibbett told us that the Meat Inspectors in the plants he dealt with were 'very assiduous in making sure that bovine offal did come out of the process and did go to where it was supposed to'. ³¹

4.706 Mr Roberts, who had served as an SEHO with Staffordshire Moorlands District Council, described a system in which there were two bins in the slaughter hall, one for SBO and the other for unfit meat. He was asked whether he saw it as the job of his Meat Inspectors to make sure the correct material went in the correct bins. He replied:

Yes. That would have been something that I saw was routinely checked on the way through the slaughterhouse, obviously do these things in the sequence. But the bins in the smaller slaughterhouse would be to one side of the slaughter hall and the meat inspector, I would expect, to instantly recognise which tissues should be going into which bins; and it was also, certainly from my recollection, routine procedure to check the dye that we had left with the slaughterhouse operators had been applied, and at the end of the day, when the meat inspector left, to reapply the dye to make sure everything was as covered as it could practically be. ³²

4.707 We have no doubt that there were others who adopted a similar approach.

4.708 Nonetheless, the need to separate SBO from other unfit meat was not a human health requirement. The only point of this separation was to assist in keeping SBO out of animal feed. This was no part of the duties of the District Councils.

4.709 In 1994 Mr Simmons reported:

It is clear that some [local authorities] see the legislation as merely an exercise in removal of SBO from carcases and preventing its use for human foodstuffs. ³³

4.710 Dr Cawthorne, drafting a submission for Mr Waldegrave, echoed Mr Simmons's concern that:

Some local authorities are less diligent than others in controlling and reconciling the movement of SBO from slaughterhouses to renderers, [possibly through the mistaken belief that the controls are aimed solely at protecting public health, overlooking the animal health implications should they find their way into animal feedstuffs]. ³⁴

The words in square brackets were not included in the final submission.

4.711 Mr Fleetwood commented on Mr Simmons's concerns:

My general perception, and it stems from the origin of these local authorities, their parent bodies are primarily almost exclusively concerned with protection of the public, protection of human health, and it would be a quite natural thing for the local authority focus to be on human health controls, not animal health. ³⁵

4.712 District Councils who took the view that the 1989 Regulations were aimed solely at protecting public health were correct. It is true that they had implications for animal health, but it is not surprising if District Councils, or officials employed by them, were less than enthusiastic about enforcing public health regulations for the sake of animal health.

4.713 Mrs Attridge made the point to us that District Councils and County Councils could be expected to cooperate in enforcement of regulations. It was suggested to her that it might not be reasonable to expect District Council officers to be assiduous in ensuring that those provisions of the 1989 Regulations, which might in practice protect animal health, were complied with for that purpose. She replied:

I find this an extraordinary suggestion. There has been a long history of co-operation between two tiers of Local Authorities and no evidence I have seen would support the Inquiry's contentions.

4.714 Mrs Brown referred us to an occasion on which the Association of County Councils, the Association of Metropolitan Authorities and the Association of District Councils had been invited to a joint meeting to discuss cooperation in controlling the disposal of SBO and other unfit material to landfill sites. ³⁶ This was one area where their respective enforcement rules overlapped.

4.715 Mr Meldrum made a similar point in evidence to us. ³⁷

Guidance to local authorities

4.716 Had District Councils been asked to cooperate with County Councils in order to facilitate the enforcement of the animal SBO ban, it may well be that in many instances they would have done so. However, no request was made by MAFF to the two tiers of local authorities to work together in the interests of animal health. No guidance was given to either County Councils or District Councils as to how MAFF expected the 1990 Order to impact on their enforcement activities.

4.717 Mr Maslin sent a copy of the 1990 Order to, among others, the associations of County Councils and District Councils, with an invitation to arrange a meeting if they wished to discuss the Order, as to its enforcement. There was no response to this invitation (see paragraphs 4.71-4.72 above). So far as the Association of District Councils is concerned, we do not find this surprising. The Order, made under the Animal Health Act 1981, was not one which District Councils were required to enforce. Nor do we think it likely to have occurred to many District Council officials that they would have a role to play in relation to regulations dealing with the supply and use of animal feed.

4.718 So far as the Association of County Councils was concerned, its silence cannot have indicated that its members perceived no problems with the enforcement of the Order. We think it likely that most Councils must have taken the view that the Order was patently unenforceable. No test existed which would demonstrate whether or not animal feed contained SBO. Mr Gresty of the North Yorkshire County Council told us that:

. . . the enforcement of the regulations without any guidance, without some partnership arrangements, I think was very much sketchy on the basis of which each county decided to do. ³⁸

I think there was some confusion at this time. There was a difference in enforcing these regulations [as against] every other animal health regulation. There was certainly not the close contact, close cooperation between MAFF and the county councils. I think it left, as I say, a somewhat uniform approach. We really were doing our own thing at the time which I think is one of our major criticisms of the operation. ³⁹

4.719 In oral evidence, Mr Meldrum explained MAFF's approach:

[In] this case we did not give detailed advice to local authorities on how we expected [the animal SBO ban] to work because we did not have time. The DVOs [Divisional Veterinary Officers] were instructed, as you know, by Mr Crawford to contact local authorities about enforcement and disposal and discuss with them the new arrangements, and to ensure that they were fully aware of the new obligations placed upon them, placed upon slaughterhouses in the first place on compliance. If we had had months and months to plan it, which we did not, we could have drawn out some guidance, no doubt, on that Order. But we were very keen to get that information out and to get the Order in place on the basis that we wished to remove that material from the animal feed supply as soon as possible after SEAC [Spongiform Encephalopathy Advisory Committee] had given us advice. You take the choice. Either you do it immediately, knowing full well that there may be some details that are not clear to local authorities, but then you advise DVOs to talk to them or you spend more time drafting advice, which will take time, and then you say: 'Here is a new Order', and you have lost two or three weeks. The view was taken by Ministers: 'We get on with it'. ⁴⁰

4.720 When asked why guidance to local authorities was not prepared for them after the Order was made, Mr Meldrum said:

One could have done, of course, but we had given quite clear advice, instructions to DVOs as to what they should do. If they had reported back to Mr Crawford, the DVOs, that there were problems of interpretation, then I have no doubt that we would have in fact gone further. We specifically said if difficulties are arising he, Iain Crawford, would like to know so that we have a picture of the position throughout the country as a whole. That was the way it was dealt with. We did not have any problems raised with us formally or informally, so far as I am aware, on the way that this Order should be put in place, or how it should be implemented in slaughterhouses. ⁴¹

4.721 In Mr Meldrum's opinion, there would have been 'a great deal of consultation' between local authorities and the Divisional Veterinary Officers (DVOs), which would have informed the local authorities of the details of the animal SBO ban in a manner superior to any written guidance:

From my experience in the field I would prefer to have discussed an issue face to face with a senior officer in a local authority and discussed the importance of the measure rather than expecting them to read a piece of paper later which might well have been put into the in-tray and then put to one side. ⁴²

4.722 On the same issue, Mrs Brown said that:

. . . our experience was that the most effective way to get the message across was to have this sort of discussion at local level with the people who had the hands-on responsibility, rather than perhaps to sit down in Tolworth or central London with the representatives of the Association who were not necessarily themselves hands on practitioners. ⁴³

4.723 We did not find this evidence realistic. It is not clear to us that there was anything that the DVOs could have said to either District Councils or County Councils about 'the details of the animal SBO ban' that would or could have resulted in its enforcement. Before they could give guidance to the local authorities, the DVOs needed themselves to understand the effect of the 1990 Order and what steps the local authorities could properly be expected to take by way of enforcement. This was not a straightforward matter, yet, as we shall show, it was not one in respect of which the DVOs were given much assistance.

Standards of local authority enforcement

4.724 We have already observed that District Councils were not likely to be enthusiastic about enforcing regulations in order to address problems of animal, rather than human, health. Quite apart from this, we received evidence that indicated very varying standards in the manner in which they performed those enforcement duties in slaughterhouses that were properly their concern, in particular those relating to standards of hygiene.

4.725 We have referred to this evidence in some detail in vol. 6: Human Health, 1989-96. In Chapter 4 of that volume we set out details of the lamentable standards of hygiene prevalent in many slaughterhouses, and the problems that resulted in very variable standards of enforcement in this area.

4.726 We have accepted the evidence of a number of witnesses that there was no general read-across from standards of enforcement of hygiene regulations to the standards applied to ensuring that unfit meat and SBO was removed from the carcass under the 1982 MSSR and the 1989 SBO Regulations. A point made was that preoccupation with the latter left Meat Inspectors little time to concentrate on the former. This is one of the reasons why we are satisfied that there was a read-across from poor standards of hygiene enforcement to the standard of enforcement of whatever Meat Inspectors and EHOs may have understood to be the requirements as to separation and staining of SBO after removal from the carcass, particularly in the gut room.

4.727 The draft report of Mr Swann of the Hygiene Advice Team (HAT) inspection of slaughterhouses after the MHS had taken over enforcement responsibilities from local authorities in 1995 gives the following picture of standards in the gut room:

The procedures for the receipt and handling of stomachs and intestines from the slaughterhall were often compromised by undermanning. Insufficient gut room staff resulted in accumulations of viscera on trays and overspill onto floors.

. . .

The standards of operation in most gut rooms, even in otherwise excellent meat plants, were often very poor. This was usually due to the practice of contracting out gut room functions to outside companies.

Washing stomachs in very heavily soiled tubs and hanging outside in a yard were common practices.

The effectiveness of procedures for disposal of intestines was variable. Green offal skips were often overfilled, with overflow, smell and fly attraction. This was a major source of complaint from neighbouring premises.

Procedures for disposal of by-products varied with the size of abattoir. In smaller plants, tubs or bins were often dirty when returned empty, unlidded and unmarked, either as unfit material, or SBO bins.

. . .

Larger plants, with automated systems and skips, were generally seen to be satisfactory. ⁴⁴

4.728 We believe that a similar picture could have been painted of conditions in the gut room of many slaughterhouses at any time between 1985 and 1995.

4.729 We had conflicting evidence of the frequency with which Meat Inspectors would visit the gut room. Mr Carrigan, who was a gut room contractor, was well qualified to speak on this topic. He told us that, in his experience, Meat Inspectors and EHOs did not visit the gut room. He said that Meat Inspectors confined their activities to the separation (on the slaughter line) of that which was not fit for human consumption from that which was. The unfit matter went to the gut room. The Meat Inspectors did not have any concerns with that which was not going for human consumption. To have walked from the clean area of the slaughterhall to the dirty area of the gut room and back would have been in conflict with restrictions designed to prevent contamination. ⁴⁵ As for EHOs, he had never seen one in the gut room in 22 years. ⁴⁶

4.730 Perhaps more important than the attitude of the Meat Inspectors was the attitude of the OVSs, in those slaughterhouses where their services were required - that is export slaughterhouses up to the beginning of 1993 and all slaughterhouses thereafter.

4.731 Mr Clark, who had served as a local authority Meat Inspector before he joined the MHS, told us that:

In the small abattoirs the gut room would not have been visited at all, because we were not there. In the larger abattoirs possibly once a day, something like that, once or twice a day, again due to staffing levels.

Q. If a visit were made to the gut room, what steps had to be taken before returning to the main part of the slaughterhouse?

A. Obviously a different hygienic practice. You would have to wash your hands, wellingtons, et cetera.

Q. Could I ask how often an Official Veterinary Surgeon would visit the gut room in the days when this was enforced by local authorities?

A. Probably never. ⁴⁷

4.732 Mr Burgess, who had worked in a slaughterhouse as an OVS, told us in a statement ⁴⁸ that the local authority which had contracted for his services reduced his hours of work so that he was unable to carry out adequate supervision. Working hours of Meat Inspectors were similarly reduced. This led to abuses of the system which included inadequate separation.

4.733 In oral evidence he told us that in the gut room there were no Meat Inspectors to supervise operations:

We did not have the staff. Legally we probably should have. ⁴⁹

4.734 Ms Hovi, who had taken her duties as an OVS particularly seriously, told us that she visited the gut room every day.

4.735 Mr Burgess and Ms Hovi gave us the following evidence of their experience of the separation of SBO from other material:

Mr. Burgess: In the morning there would be some separate containers, coloured sometimes, occasionally they were marked, and we used to kill in excess sometimes of 300 cattle a day. By the end of the day, because I had to leave by about 2 o'clock, things gradually started to deteriorate and the actual separation between the bins would be less obvious than it was earlier on, the level of waste material would build up in the abattoir. It was a question of the person cutting it off and throwing it into the bin, occasionally they miss. Unless you are actually there watching it constantly you could not be sure it was being done absolutely correctly. But there were attempts made to separate it, but in practical terms it is actually quite difficult to do unless the line speed is such and there are enough operatives there that it can be done properly. It was adequate, but I would not say it was foolproof. ⁵⁰

Ms Hovi: This particular abattoir, when I was working there, the spleens were put into the petfood bin. The bins were clearly separated at the abattoir and apart from the general confusion that Mr Burgess and Mr Swann described, the system seemed to operate fairly well apart from the spleens. The meat inspector who started working at the abattoir at the same time as me came to report to me immediately that the abattoir management had reported to him that the spleens can go in the pet food bin. That was their practice and asked me what my opinion on that was. We immediately enforced obviously a proper disposal of the spleens into the SBO bin and it was not questioned by the management after that, they obviously just tried it on. ⁵¹

4.736 Mr Burgess and Ms Hovi were impressive witnesses, and OVSs of their calibre would have taken their enforcement duties seriously. We had evidence, however, of difficulty in recruiting OVSs, and of the fact that many did not integrate well into the enforcement system.

4.737 Mr Brian Etheridge, who had been Assistant Secretary for Environmental Health with the Association of District Councils (ADC) told us:

. . . local authorities were having enormous difficulty in securing the offices of veterinary surgeons. Those that they did were often engaged in private practice and therefore were not able to spend the greatest part of their commitment to this post. Some local authorities were also complaining to us that once at the plant they were unsure of their responsibilities, were not entirely sure why they were there. And local authorities, I think sadly, in a way, did not encourage the employment of these vets to become part of the management system of the local authority, so perhaps understandably they felt slightly detached and confused. ⁵²

4.738 He added:

There was some professional difficulty between veterinary surgeons and Chief EHOs. The perception as I recall among Chief EHOs at the time was that they were not entirely sure why they were having to employ these people sometimes at extremely elevated costs. And in fact very cynically some local authorities have said to us, and we have recorded, that they felt they had to do this merely because the regulations said so. And their objective was to fulfil the regulations by employing them and largely left them to their own devices beyond that. ⁵³

4.739 Mr Du Val, an EHO who joined LACOTS in 1991, elaborated:

There was a concern, from the local authority side, that one was having an official imposed on you as part of the enforcement regime where they, essentially, had no training in enforcement, and their conversion course from a veterinary practice to being able to enter the slaughterhouse was essentially just a five-day course without an examination, which really did not cover enforcement of the regulations that there were there. I know it was a recurring concern that was expressed to them, with that lack of enforcement perspective, to say that perhaps enforcement in these situations is not seen as that important. ⁵⁴

Deregulation

4.740 A further point made by a number of witnesses was the dampening effect of the Government's deregulation initiative upon the enthusiasm with which the SBO Regulations were enforced.

4.741 A minute of 14 October 1992 recorded views expressed by Mr Gummer in the context of a European Directive on red meat. This included the following passage:

Overall, the Minister said that he wished to give a policy steer. The mood of the public had changed; they were now more worried about overzealous enforcement than about the risk of food poisoning. MAFF's policies should therefore be as relaxed as possible while still protecting public health. ⁵⁵

4.742 Mr Mike Ashley, who had environmental health responsibilities for both the Association of District Councils ⁵⁶ and the Local Government Association, ⁵⁷ told us:

. . . the associations were concerned about the government policy in respect of a strong deregulatory campaign, and also the linked - I think they bounced off each other - and the linked sort of media campaign that was run. It was particularly associated with [a] journalist Mr Christopher Booker who wrote a series of articles around this time, who very much portrayed local authority enforcement officials as 'little Hitlers'. That in many ways picked up and reflected an increasing government campaign to go for so-called 'light-touch' regulation. ⁵⁸

. . . the Government was clearly signalling in various ways that a pretty light touch in applying this and many other regulations ought to be used. And frankly it did contribute to a considerable level of confusion and concern in the regulatory enforcement community generally about what they were supposed to do. ⁵⁹

4.743 Mr Etheridge summarised the position in his witness statement as follows:

The government was pursuing very vigorously its deregulation agenda and was very public in its condemnation of alleged overzealous application of regulations by local authorities. It was imploring local authorities to adopt the so-called 'soft touch' to enforcement.

Local authorities were also grappling with the introduction of a series of new regulations which were often implemented at short notice and came into force before copies were available. Guidance often followed rather than preceded regulations. There was also some hostility to the introduction of the need for veterinary surgeon presence. MAFF's position appeared unclear, its guidance on the need and extent of veterinary presence constantly changing as its interpretation of the relevant Directives was modified.

The overall state of local authority meat inspection at the time was a service in low morale, subject to conflicting messages from the centre, receiving little support locally and having to carry the burden of additional veterinary presence and an extremely disgruntled trade. ⁶⁰

4.744 This picture related to the years leading up to the introduction of the Meat Hygiene Service, and we think that morale of those employed by local authorities in slaughterhouses was likely to have been at its lowest during this period. When the MHS replaced the local authorities as the enforcement authority in slaughterhouses, Mr McNeill, the Chief Executive, described what he found:

We endeavoured to find out what level of enforcement activity had been employed by local authorities in enforcing the regulations and were unable to get any clear picture, although it did not appear to be of any great substance. And in discussions with staff, particularly as we took a much more robust enforcement line, on issues such as presenting carcasses with spinal cord present and what not, it became apparent to us that there was, I think it would be fair to say, a reluctance on the part of some of our veterinary surgeons and indeed meat inspection staff to move down this more formal enforcement road. Previously in previous cases it had been perhaps a more relaxed approach to enforcement. ⁶¹

Conclusions on enforcement of the Regulations in slaughterhouses

4.745 Mr McNeill's description, quoted in the previous paragraph, takes us back to the passages in vol. 6: Human Health, 1989-96 to which we referred earlier in this section. In retrospect, it is not surprising that there were serious shortcomings in the enforcement of MAFF's policy of keeping SBOs out of the animal feed chain. We turn next to consider why it was that it took the Veterinary Field Service (VFS), who was monitoring the implementation and enforcement of the animal SBO ban, so long to become aware of these shortcomings.