Volume 5: Animal Health, 1989-96
4b. Implementation, enforcement and monitoring of the animal SBO ban: discussion
Consideration given to the animal SBO ban between 1990 and 1994
Staining
Weight checks
Adequacy of monitoring
The monitoring of enforcement in slaughterhouses
Monitoring of enforcement at renderers
Monitoring of enforcement at collection centres
Monitoring of enforcement in knacker's yards and hunt kennels
Conclusions on monitoring
Failure to take action before 1994
Conclusions on failure to take action before 1994
Did MAFF move with adequate speed to introduce the new scheme?

4.855 Thus far we have been considering whether shortcomings in the 1990 Order should have been addressed at the time that it was made. We now turn to consider whether shortcomings in the Regulations, or the manner in which they were operating, should have been identified and addressed before 1994.

Staining

4.856 While we have criticised Mr Meldrum for failing to identify the inadequacies of the 1990 Order at the time it was made, we should record our appreciation of the diligence that he showed in seeking to ensure that the ban operated satisfactorily in the years that followed. Time and again it was Mr Meldrum, rather than one of his subordinates, who gave directions aimed at improving the efficacy of the ban.

4.857 As soon as the 1990 Order took effect, Mr Meldrum asked Mr Lawrence whether there were any means of identifying SBO in animal feed. This led Mr Lawrence to investigate the possibility of incorporating some form of marker in the SBO (see paragraph 4.118 above). At the meeting chaired by Mr Meldrum on 9 November 1990, it was agreed that Mr Lawrence and Mr Kevin Taylor should pursue with CVL the possibility of a simple cheap marker or dye (see paragraph 4.121 above above). None of those involved has any recollection as to what transpired in relation to this enquiry. Mr Taylor told us that he had spoken to Mr Lawrence about this and that neither of them had any recollection of what they did about it. ¹

4.858 Mr Lowson told us that it would have been his responsibility to see what happened about this, but he did not now know what had happened. ²

4.859 Mr Meldrum suggested that the whole issue might have been 'subsumed' within the development of the ELISA test that was taking place at the Worcester Veterinary Investigation (VI) Centre. ³ This does not strike us as very probable.

4.860 We regret that we cannot resolve what happened in relation to this matter. Had a suitable stain or marker been identified at this stage of the story, it would have been of value. A requirement to mark SBO with a separate stain would have focused attention on the need for separation and facilitated identification of SBO in transit and on arrival at the renderers. If the evidence showed that Mr Taylor and Mr Lawrence had let the search for a marker lapse without good reason, we would have been critical of their conduct. On the face of it there appears to have been a lack of diligence in pursuing this matter, but we are conscious that, after a lapse of ten years, there may be an explanation that has simply been forgotten. In the circumstances, we do not consider it fair to criticise individuals.

Weight checks

4.861 The consideration given at the meeting on 29 October 1990, chaired by Mr Andrews, to the desirability of policing the animal SBO ban was commendable (see paragraph 4.90 above). It may well have led to the series of early checks on renderers and slaughterhouses carried out on Mr Meldrum's instructions, although we could equally envisage him giving these on his own initiative. It was in response to Mr Andrews's instructions that Mr Lawrence put forward his suggestions for monitoring throughput of SBO material by the use of weight checks (see paragraph 4.111 above).

4.862 Mr Lawrence's suggestions were received with some scepticism by Mr Hutchins. ⁴ Mr Crawford told us that he agreed with Mr Hutchins's comments. ⁵ Mr Baker told us that he would not have considered weight checks to be practicably viable. ⁶ Mr Lawrence's suggestions were not taken further.

4.863 The requirement to keep records of weights at all stages of the SBO's progress from the slaughterhouse or other place of origin to final disposal was one of the requirements of the 1995 SBO Order. This requirement replaced the old system of movement permits which, as we have seen, did not operate effectively in practice. The practical problems of Mr Lawrence's scheme identified by Mr Hutchins were, we believe, reasonable grounds for not pursuing the scheme further. Mr Crawford told us that attempts to employ weight checks in 1995 proved to be very difficult and not particularly worthwhile because there were so many variables. ⁷ We do not believe that if the Veterinary Field Service (VFS) had attempted to monitor throughput of SBO by weight checks in 1990 in the manner suggested by Mr Lawrence this would have proved viable.

4.864 Mr Lawrence raised the suggestion of weight checks again in March 1991 (see paragraph 4.163 above). Once again they were not pursued, and for the same reason. In August of the following year, however, the veterinary field staff were recommended to make occasional weight checks at renderers, in order to compare SBO raw material input and MBM yield. Such checks had become practical because renderers had been required to keep records of these weights under the 1991 Order for licensing disposal of SBO-derived protein (see paragraph 4.190 above). Thus part of Mr Lawrence's overall scheme was ultimately adopted.

Adequacy of monitoring

4.865 The activities of the VFS in monitoring the implementation of the animal SBO ban were bedevilled by the following complicating factors:

1. the lack of a statutory role;
2. the lack of clearly defined obligations to be monitored;
3. the lack of powers of entry;
4. uncertainty as to the responsibility for directing these monitoring activities.

(i) Lack of a statutory role

4.866 Mr Meldrum observed in a witness statement:

It is clear that the SVS had a responsibility set by Ministers to monitor the efficacy of the arrangements put in place to control/eradicate disease and to protect the public and to draw any deficiencies to the attention of Ministers with a recommendation as to how the problem could be resolved. ⁸

4.867 A statement made by Mr Crawford expanded on the position:

The State Veterinary Service (SVS) was, and still is, a part of MAFF. It had no enforcement role placed on it in relation to the Regulations by any of the relevant legislation. However, Ministers felt that it would be helpful if the SVS offered advice and guidance to Local Authorities, and thus indirectly, to operators of slaughterhouses, knacker's yards and hunt kennels, in order to assist them in complying fully with the Regulations. This assistance was given by way of periodic visits by Veterinary Field Service (VFS) officers to those institutions, following which a report would be written. If any breaches were found, they would be reported to the relevant Local Authority. Advice would also be given to the relevant Local Authority as to how such breaches might be corrected . . . ⁹

It must be stressed that this assistance was not a formal obligation placed upon the SVS under the legislation introducing the Regulations. Rather, Ministers felt that an extra layer of support would be valuable to an industry that had seen so many changes taking place and new obligations put upon it. Ministers therefore gave MAFF the task of undertaking this support work. Equally important was the fact that by monitoring the Regulations in this way, MAFF could decide whether they were adequate, or whether further legislative change was needed. ¹⁰

4.868 We had no direct evidence of Ministers conferring these roles on the VFS. The advising and monitoring roles of the VFS in relation to the enforcement obligations of local authorities appear to be of long standing. The roles were plainly of value. Often, however, the SVS lacked the statutory powers that were needed if these roles were to be properly performed. This was certainly the case in relation to BSE, as appears below.

(ii) Lack of clearly defined obligations to be monitored

4.869 We have dealt with this at length earlier in the Discussion (see paragraph 4.644 above).

(iii) Lack of powers of entry

4.870 When the Food Safety Act 1990 replaced the Food Act 1984, the SVS lost its powers of entry to slaughterhouses and knacker's yards, previously available in order to check upon compliance with Regulations made under that legislation (see paragraph 4.26 above).

4.871 The SVS had powers of entry under the Animal Health Act 1981, but was only entitled to use this power for monitoring compliance with the Regulations where there were reasonable grounds for supposing that they were not being complied with (see paragraph 4.23 above). As the 1990 Order did not, as we have explained, impose obligations in slaughterhouses, the SVS had no right of entry to those premises for the purpose of monitoring implementation of the animal SBO ban.

4.872 The lack of access rights did not prevent members of the VFS from entering slaughterhouses or other premises in order to carry out their monitoring function. Mr Crawford told us that lack of access rights did not prevent the obtaining of information, although sometimes it made it more difficult:

I do not think we had any insurmountable problems in collecting the information. I think we got the information as we required it, but it did put the staff in the field under some pressure at times, and the antagonism, if you like, varied from one part of the country to the other. In some parts our staff had real problems in making joint visits and having cooperation; in other parts the relationships were extremely good. To an extent, it was a conflict, if you like, between veterinary presence and the EHO presence in abattoirs, where environmental health officers had the responsibility and saw no reason why there should be any veterinary involvement, and our staff had to work in a diplomatic fashion with these people to get cooperation, which they always managed to get, but it could be and was difficult on some occasions. ¹¹

4.873 Because they had no rights of entry, Mr Crawford told us that members of the VFS would normally arrange to visit slaughterhouses with the Environmental Health Officers (EHOs) who were responsible for them. ¹² Clearly, the lack of entry rights must have been an inhibition to the making of unannounced visits.

(iv) Uncertainty as to responsibilities for direction of the operations

4.874 The monitoring obligations that we have examined in this chapter were carried out in support of the enforcement of the animal SBO ban. One might have expected them to be directed by Mr Kevin Taylor as veterinary head of the Notifiable Diseases Section and subsequently Assistant Chief Veterinary Officer (ACVO) responsible for animal health and welfare. He told us, however:

I had no direct responsibility for advising on the SBO regulations, or monitoring compliance with them, before Dr Cawthorne joined my Section in April 1995, bringing with him the veterinary responsibilities of his previous post as Head of the Animal Health (Zoonoses) Division (which was being disbanded as a unified Division). SBO controls were mainly exercised at the slaughterhouse, and responsibility for veterinary advice therefore fell to the Section headed by my fellow ACVO, Mr Baker. ¹³

4.875 In oral evidence he explained why it was that responsibility for the implementation of the animal SBO ban in the field did not fall to him:

For whatever reason, and even I myself find this quite difficult to understand, this is not an area that fell to me. You will see that quite clearly by looking at the Animal Health circulars, the circular letters, the exchanges of minutes. You see, the animal SBO ban in a sense simply extended a ban which was already in place, the human SBO ban, and the action was taken at slaughterhouses and downstream from slaughterhouses.

Thinking back to what I said in my opening statement about responsibilities, it sort of naturally fell to the Meat Hygiene Section, even though primarily their concern was public health, in the same way that I did certain things, or advised on certain things which were done for public health reasons but they affected the animals on the farm.

So we were building on something that was already there and I think it was natural that the surveillance and the monitoring remained with the meat hygiene veterinary staff because of this pre/post-abattoir split.

If you look at the animal health circulars on the subject which were issued, they were all issued by Meat Hygiene Division. The returns were collated by the Meat Hygiene Division vets, the reports were sent to the Director of the Veterinary Field Service, but they were copied to others, including me, for information. That is how the system worked. ¹⁴

4.876 Mrs Attridge explained that, while her administrative division had responsibility for monitoring and keeping the regulations in relation to the animal SBO ban under review, her 'eyes and ears' in doing so were the field vets. ¹⁵ Mrs Attridge went on to say that the Meat Hygiene vets would have had an 'eyes and ears function' for the benefit of the Animal Health Division, although the Meat Hygiene Division was primarily responsible for regulations safeguarding human health. ¹⁶ Mr Baker's staff, Mr Hutchins, or Mr Simmons, were the experts involved in monitoring and reviewing the SBO Regulations as applied in the field, but the Director of Field Services and the CVO would be very much involved. 'Those two both took an extremely acute interest in this and the reports were all going to them and they would have brought in any others they considered necessary.' ¹⁷

4.877 Mr Baker told us that he was initially in the lead in implementing Mr Andrews's request in November 1990 for policing action of the animal SBO ban. ¹⁸ Subsequently the responsibility for monitoring the handling of SBO material in slaughterhouses passed to Mr Crawford. Thereafter, Mr Baker received summaries of the reports from the field as a matter of 'politeness as much as anything else' because the summaries were being prepared by one of his staff. ¹⁹

4.878 It was pointed out to Mr Baker that the initiative for the review of monitoring the handling of SBO in April 1994 came from Mr Meldrum. He was asked whether the initiative should not have come from his department. Mr Baker replied that he was not sure that it should have come from his department. Mr Meldrum, because of his previous work, was in touch with the renderers far more than any of the others involved. ²⁰

4.879 In a statement to the Inquiry Mr Crawford explained that it was no part of his responsibilities to oversee the amendment of the Regulations:

My responsibility was to advise on the practical problems of implementing policy in the field, and how such matters might affect the VFS, rather than to assist in the production of policy. I did not have any responsibility for amending and/or overseeing the amendment of the Regulations, or for making policy decisions.

Throughout the period up to April 1994, there was extensive monitoring and analysis of how the Regulations were being applied in practice. I received regular reports of the situation in the field, and where problems were identified, I was satisfied that staff dealt with them appropriately. I also regularly analysed the application of the Regulations in practice, as far as I was able. When I thought changes needed to be made, I issued the necessary instructions to the staff of the VFS, either of my own volition, or following discussion with policy-making colleagues . . .

. . .

As I have explained above I had very little involvement in advising Ministers on the adequacy of the Regulations in practice. My role with senior policymakers would be to ensure that they were copied in on reports of the visits being made to slaughterhouses, knacker's yards and hunt kennels, and any other relevant information from the VFS. ²¹

4.880 We have found this a somewhat confusing picture. No one person appears to have been responsible for reviewing the adequacy of the monitoring of the animal SBO ban. The Regulations being enforced were largely the 1989 Regulations, which were chiefly concerned with slaughterhouse activities. This explains the input from the Meat Hygiene veterinarians of the SVS. While Mr Crawford had overall responsibility for directing the operations of the VFS and ensuring that it provided the information that policy-makers needed, many of the initiatives came from Mr Meldrum.

The monitoring of enforcement in slaughterhouses

4.881 Mr Baker's first request to DVOs to provide information in relation to slaughterhouses simply stated 'We would like to know how slaughterhouses are handling specified offals' (see paragraph 4.98 above). The response to this varied so much in format and detail that it was useless. ²² A further round of reports was then called for, for which a pro forma was provided. This called for information in relation to brain removal, staining and movement permits (see paragraph 4.98 above). At this stage the importance of ensuring the separation of SBO from other material does not appear to have been appreciated.

4.882 Mr Hutchins's follow-up of deficiencies was exemplary. So was Mr Crawford's decision to call for a third round of reports (see paragraph 4.136 above). These used the same pro forma as before. Once again there was an exemplary follow-up of deficiencies. This was, for the time being, the last series of reports that was called for specifically relating to the SBO Regulations.

4.883 Six months later Mr Meldrum intervened. He had heard from a reliable source within the rendering industry that significant quantities of SBO were not being stained. Mr Crawford's reaction was to call for 'the occasional unannounced visit'. The AHC which was sent out in compliance with these instructions spoke simply of 'significant shortfalls in compliance with the Regulations' (see paragraphs 4.144-4.147 above).

4.884 We move on a further year to 7 August 1992. AHC 92/94 was sent out reporting 'quite a number' of reports from industry contacts alleging that SBO was not being kept separate from other material and thus was being incorporated in animal feed. The circular emphasised, for the first time, the importance of ensuring that SBO was kept separate from other material at the abattoir and during transportation to rendering plants. Renderers were now being required to record, on movement licences for protein derived from SBO, the weight of the incoming material and its source. The AHC called for spot checks on this information at the sources in question. ²³

4.885 This AHC was issued from Animal Health (Disease Control) Division Branch B, rather than the usual source, Meat Hygiene Division. We have difficulty in envisaging how this check was intended to work. Presumably it was intended to identify any discrepancy between the weight that left the slaughterhouse and the weight that arrived at the renderers. This was the exercise suggested by Mr Lawrence, which had been ruled out as unrealistic because any calculations of weight at the slaughterhouse would be unreliable.

4.886 The next step in the story was the introduction of Mr Simmons's 'cradle to grave' monitoring on Form MH6 (see paragraph 4.255 above). This was a significant improvement in the system, for which Mr Simmons deserves commendation. In particular, it called for confirmation that separation between SBO and other material was satisfactory at all stages. Without a marker or separate dye this was, however, a question that was easier to ask than to answer. The circular called for occasional unannounced visits to slaughterhouses.

4.887 Mr Crawford's reminder to VOs of the need to review arrangements for the separation of SBO in abattoirs on 1 February 1994 produced reports which indicated that separation was generally adequate, but that compliance with staining requirements was patchy (see paragraph 4.287 above).

4.888 The next step in the story was the tightening up of monitoring in slaughterhouses effected by AHC 94/106, ²⁴ which we have described above. This was the last stage before the MHS replaced District Councils as the enforcement authority in slaughterhouses.

Conclusions on monitoring in slaughterhouses

4.889 While initially the guidance given to the Veterinary Field Service as to what it should be looking for in the course of monitoring left something to be desired, there was a steady process of improving the instructions given until, in 1994, they were commendable. Having regard to the absence of satisfactory requirements for separation and distinctive staining of SBO in the Regulations and the other factors referred to at paragraph 4.285 above, we have concluded that this aspect of the monitoring story constituted an adequate response on the part of those directing the monitoring of slaughterhouses.

Monitoring of enforcement at renderers

4.890 In the first years after the introduction of the animal SBO ban officials were clearly much more concerned at the risk that SBO might get into the animal feed chain at renderers than in slaughterhouses. We have no criticism to make of the returns that were called for or their frequency during the first two years that the ban was in operation. The additional weight checks that were introduced in August 1992, once provision of the data had been made a requirement under the scheme for licensing the disposal of protein, was a commendable addition to the monitoring scheme.

4.891 The Achilles heel in relation to the attention given to rendering was the delay in tackling the problem of contamination where common plant was used to render both SBO and other material. The importance of addressing this problem was identified both by Mr Hutchins and by Mr Meldrum early in 1991 (see paragraphs 4.154-4.158 above). Serious deficiencies in relation to precautions against contamination were identified in May 1991 (see paragraph 4.168 above). Once again Mr Meldrum intervened and the result of his intervention was the preparation and agreement with the industry of the Code of Practice. In the absence of any regulations making cross-contamination an offence, the negotiation of agreement to a voluntary Code was a sensible approach. It was not introduced until August 1992. We observe that the negotiation and introduction of this Code went far beyond the monitoring function of the VFS. It was an important non-statutory step in implementing the policy of keeping SBO out of animal feed. Checking up on the due implementation of the Code thereafter became part of the monitoring function of the VFS.

4.892 Insofar as there is criticism to be made of the failure to address the problem of cross-contamination at the outset, we would direct this to the initial failure to impose any statutory obligation to keep SBO separate from other material. Had there been such an obligation, MAFF and the County Councils together would have been in a position to require more rapid steps to be taken by renderers to deal with this problem.

Monitoring of enforcement at collection centres

4.893 Until 1995 there were no regulations requiring separation to be maintained at collection centres. There was no local authority enforcement at collection centres, so far as we are aware. Once this gap in the enforcement system had been identified, the VFS took on the role of attempting to check the adequacy of separation at collection centres (see paragraph 4.150 above). In the absence of a distinctive dye to assist in identifying SBO, separation at collection centres depended, as was observed, largely on trust.

Monitoring of enforcement in knacker's yards and hunt kennels

4.894 As we have already observed, the absence of any Regulations dealing specifically with SBO at knacker's yards and hunt kennels, other than the 1990 Order itself, as amended in 1991, had the result that monitoring appears to have been directed to compliance with the 1982 MSSR. This was manifestly unsatisfactory. The cause was the failure to think through the requirements of the animal SBO ban when drafting the initial Order.

Conclusions on monitoring

4.895 We have in the course of the Inquiry cast a very critical eye over the actions taken to monitor the animal SBO ban, provoking indignant responses to our concerns that some involved might have been giving no more than superficial consideration to the implementation of the ban. We have concluded that this was not the case. There were unsatisfactory features of the monitoring, but these were largely the consequence of the absence of a clear regulatory scheme and do not constitute additional grounds for criticism. For the reasons given, we are satisfied that any such concerns were unfounded. There remains, however, one fundamental concern which we now turn to consider.

Failure to take action before 1994

4.896 Returns from the VFS suggested that SBO was being handled satisfactorily in a manner which kept it out of the animal feed chain. These official returns were at odds with periodic unofficial reports that the staining requirement of the 1989 Regulations was being flouted and that SBO was being processed into protein that was going into animal feed. In 1994 there was a fundamental review of the Regulations and in 1995 a national surveillance campaign, which disclosed that the unofficial reports had been well founded. Our concern was that these unofficial reports should have led to action of the kind taken in 1994 at a much earlier stage in the story.

4.897 The reply given by the witnesses with whom we raised this concern was that the action taken in 1994 was a response to an accumulation of factors which could not reasonably have been appreciated at an earlier stage.

4.898 In a written statement Mr Meldrum gave the following explanation as to why action was taken in 1994 and not before:

The recognition that the arrangements for disposal of SBOs required a full review was the culmination of four years of experience from (i) slaughterhouse operators, renderers, etc who were responsible for complying with and executing the SBO regulations, (ii) enforcement of the SBO regulations by Local Authorities (both district and borough councils) and (iii) SVS staff monitoring and providing guidance on the SBO regulations. It should not be forgotten that at the time they were introduced the SBO regulations were an unprecedented (and far seeing) piece of legislation. As far as I am aware, it was the first time action had been taken against a perceived risk from potentially sub-clinically infected animals through the removal of specific parts of the carcass from animals that appeared totally healthy and normal at the time of slaughter.

From the period of the introduction of the SBO regulations in November 1989 to the meetings in April/May 1994, MAFF undertook a series of inspection visits to slaughterhouses, rendering plants, knacker's yards and other premises to monitor compliance with the SBO regulations and the 1990 Order . . . It was only through the visits conducted over that period and through information received from industry contacts on allegations of non-compliance that a picture could be built up of the handling and disposal of SBOs throughout the chain and appropriate action taken. The difficulty in gaining that complete picture stems from the fact that MAFF had no role in the enforcement of the SBO regulations and the 1990 Order and that the presence of SVS staff in the relevant premises was bound to be extremely limited, although all of this changed on 1 April 1995 when the Meat Hygiene Service took over the enforcement responsibility from Local Authorities. Further, some of the information on non-compliance that was received within MAFF were only unsubstantiated allegations and it was difficult for SVS staff to find evidence of actual wrong-doing.

. . .

In 1994 there was a combination of factors which included (i) the increasing numbers of BABs and investigations into the possible source of the feed contamination that may have been the cause, (ii) knowledge obtained from the continuing epidemiological investigations and the case control study, (iii) knowledge of the time/temperature required for deactivation of the BSE agent (and consequent discovery that the agent survived in two of the makes of plant then in use in the UK), and (iv) industry reports on circumvention of the legislation being confirmed on 25 March 1994 after unannounced visits by SVS staff . . . All of these factors pointed to the need for a comprehensive review of the controls on the disposal of SBOs. Such a combination of factors did not, and indeed could not have, existed in September 1990. ²⁵

4.899 Mr Meldrum also made the point that, because the Meat Hygiene Service was about to take over the District Councils' enforcement role under the SBO Regulations, changes to secondary legislation were required and it was thus an opportune moment to review the legislative arrangements for the SBO controls. ²⁶

4.900 Mr Crawford said that by February 1994 'information was beginning to build up' of non-compliance with the Regulations. 'Reports were becoming more regular from sources that there was a problem.' ²⁷

4.901 Mr Taylor gave evidence to similar effect:

The information obtained from [monitoring] exercises, together with the results of research (the rendering and attack rate studies), epidemiological studies, observation of the progress of the epidemic, and actual evidence of failure to comply with SBO controls, eventually accumulated to provide a body of information which indicated the need to carry out a thorough review of the controls, which in turn led to the changes introduced in 1995. The conclusions which were reached in May 1994 were based on an assessment of all the information and evidence then available. If a similar meeting had been held a couple of years earlier, it is most unlikely that the same conclusions would have been reached, because the information and evidence available in 1992 was different. ²⁸

Conclusions on failure to take action before 1994

4.902 We were not greatly impressed with the suggestion that it was not until 1994 that MAFF had cogent indications that the animal SBO ban was being evaded. We have identified a series of reports from external sources that SBO was not being stained and was being processed for animal feed:

1. Reports to Mr Lawrence 'on the grapevine' in November 1990 (see paragraph 4.109 above).
2. A report from Mr Lawrence of a note from a reliable but unnamed source alleging wrong-doing in respect of certain rendering plants in March 1991 (see paragraph 4.162 above).
3. Information received by Mr Meldrum from 'other sources' which caused him extreme concern in June 1991 (see paragraph 4.145 above).
4. Three'phone calls to Mr Lawrence in the space of two days in June 1992 alleging that SBO was being processed to make MBM that was being used in feedstuffs (see paragraph 4.209 above).
5. Reports from industry that some MBM derived from SBO was going into animal feed recorded in August 1992 (see paragraph 4.213 above).

4.903 These are in addition to the reports in 1994 which led to the unannounced checks on renderers. We believe that these reports constituted a powerful indication that the animal SBO ban was being breached. The investigations headed by Mr Lawrence into standards of local authority enforcement of hygiene regulations in slaughterhouses should have sufficed to dispel any illusions that officials might have had as to there being a uniformly high standard of local authority enforcement arrangements around the country.

4.904 MAFF officials' reaction to these unofficial reports was steadily to step up the stringency of monitoring by the VFS until, finally, this confirmed the unofficial reports. Once again we have concluded that the failure to respond more positively is attributable to the failure to focus at the outset on the possibility that a very small quantity of infectious material might suffice to transmit BSE to cattle. As the years passed, without any cases of transmission of BSE to pigs or poultry, it must increasingly have seemed that the concerns which had given rise to the animal SBO ban were unfounded.

4.905 We received one cogent piece of evidence of MAFF officials' reaction to the animal SBO ban at the end of 1993. This was an extract from a minute of an UKRA Council meeting held on 15 December, at which SBO was discussed. It read:

Problem - SBO regs not working? Renderers not sure if materials are SBO or not. Regulation of input and output et cetera is voluntary. MAFF do not seem concerned or bother to enforce. Why? Ruminant recycling ban - this is the main safeguard say MAFF. ²⁹

4.906 Mr Stephen Woodgate, Chairman of UKRA Technical Committee, who made the note, told us that this expressed his feelings at the time, following 'extensive discussions with a lot of people from MAFF'. His personal view was that MAFF felt that the ruminant feed ban was the main mechanism of disease control:

The SBO ban was something, I believe, they felt was sort of important but, at the time, I do not think they really understood or realised how important SBOs were. [BABs] had not started to show themselves yet, the pathogenesis study which eventually showed one gram of material to be enough to be an infective dose did not come through until 1994. Those elements that were subsequently found were not understood, were not well understood. My feeling was, with colleagues, that the SBO ban was not as strictly adhered to, because perhaps it was not felt to be that important.

. . .

SBO, which may be filtering into meat and bonemeal, which is then going into pig and poultry feed - I felt their opinion was that was of lesser importance [than the RFB]. It was subsequently, as I said, the one gram issue, the looking at feedmills and realising that there could be possible cross-contamination, and the general coming together of the [BABs], that if I put it in my own language the penny clicked that perhaps this was more important; and the feeling was that the tightening up of all these regulations all came in line with the new evidence as it came on board. ³⁰

4.907 We believe that Mr Woodgate's analysis was correct. Had MAFF officials had reason to believe that the animal SBO ban was an essential protection for animal health, we are confident that they would have put in hand a thorough review of the system prior to 1994.

4.908 The factor which we believe made all the difference in 1994 was the appreciation that MBM had been getting into ruminant feed by cross-contamination in feedmills and infecting cattle with BSE, not merely before the introduction of the animal SBO ban, but after the date that the ban came into effect. Of the 6,271 BABs confirmed by the end of 1993, only five had been born after 1 July 1990. A further 18 BABs born after that date were confirmed in the first quarter of 1994.

4.909 In these circumstances, Mr Bradley concluded that 'We have to quickly and effectively re-assess and, if necessary, improve the policing of the controls both via MAFF and the local authorities' (see paragraph 4.297 above). We believe that Mr Meldrum and his colleagues reached the same conclusion. Are they to be criticised for not reaching it sooner? We have concluded that there is nothing to add to our criticism of the original failure to appreciate the danger of cross-contamination at the time of introduction of the ruminant feed ban. Given that failure, we do not consider that the manner in which MAFF officials performed their role of policing the animal SBO ban fell outside the range of acceptable responses to the facts as they appeared at the time.

Did MAFF move with adequate speed to introduce the new scheme?

4.910 The shortcomings in the existing regulations had been identified by the end of May 1994. The requirement for a distinctive stain for SBO was introduced on 1 April 1995. The consolidated regulations making up the new scheme did not come into force until 15 August 1995. Does this delay reflect inadequacies in responding to the shortcomings that had been identified?

4.911 Dr Cawthorne was asked by Mr Haddon to take over from Mr Eddy responsibility for progressing legislative changes to the SBO Regulations in July 1994. ³¹ By 10 August Dr Cawthorne had prepared a submission to Ministers and carried out internal consultation with his colleagues as to its contents. The submission dealt at length with this complex topic with admirable clarity. Dr Cawthorne had lost no time in the first stage of the task entrusted to him by Mr Haddon.

4.912 In his submission to Ministers, Dr Cawthorne dealt with timing:

The introduction of these changes is not time limited but having identified deficiencies in the way SBO is being collected and disposed of, officials believe corrective action should be taken without unnecessary delay. Many of the changes are not controversial but some, such as the possibility of requiring SBO to be disposed of in dedicated rendering facilities, could have important economic consequences for the industry and adequate time is required for their discussion. Officials would therefore like to consult with interested organisations as soon as possible with a view to reporting back to Ministers in October. ³²

4.913 What then ensued was a thorough consultation exercise, which led to a valuable reconsideration of the movement permit system. Ministerial approval was given to the revised proposals on 19 January 1995. The next few months saw internal discussions as to the form of the Order, and the addition to it of a prohibition on the removal of brains and eyeballs from the skull. This reflected an increased concern about infectivity, following the interim result of the attack rate experiment. This involved a further short period of consultation (see paragraphs 4.414-4.415 above).

4.914 The requirement for a separate stain for SBO was introduced on 1 April 1995, when the MHS took over enforcement duties in slaughterhouses from the District Councils. The Specified Bovine Offal Order 1995, which made the remainder of the amendments, was made on 20 July and came into effect on 15 August.

4.915 This sequence of events showed a lack of urgency. The steady course of the legislative process resulted in a well considered and well constructed Statutory Instrument. We feel, however, that this could have been achieved in a shorter timescale. Is the failure to move faster a matter for criticism?

4.916 We have decided that it is not. The new scheme could not sensibly have been introduced before 1 April 1995, when the MHS took over the enforcement functions from the District Councils. In the event, a further three months or so elapsed before the Order took effect. It is really only that period that is at issue. We consider that, having regard to the situation as it appeared at the time, this degree of delay can be excused.

4.917 Although the Regulations had proved less than watertight, the combined effect of the RFB and the animal SBO ban had removed the major source of infection. It was reasonable to expect that, by 1994, infectivity caused by contamination of cattle feed would have been reduced to fairly modest proportions. Looking back from a standpoint of 1 June 2000, we can see that the number of BABs confirmed by then, which had been born in 1994, was just over 1,000. Had MAFF moved faster, this number would have been commensurately reduced, but achieving such a result was not a goal of critical importance. While Dr Cawthorne can claim no credit for expedition, he can claim credit for an admirable new statutory code. The result of that code, and of the diligence with which it was enforced, is demonstrated by the fact that, as at 1 June 2000, no more than 30 BABs had been confirmed among cattle born in or after September 1995.