Volume 6: Human Health, 1989-96
3. Introduction of the ban on Specified Bovine Offal
Discussion on the preparation of the Regulations
Should contamination of MRM have been anticipated?
Should the infectivity of the dorsal root ganglia have been suspected?
Was adequate consideration given to MRM when preparing the SBO Regulations?
Consideration of MRM by DH
The Ministers' decision
Enforcement

Should contamination of MRM have been anticipated?

3.699 On 12 April 1989 Mr Bradley included in a manuscript note to Dr Watson the following advice:

It would seem sensible that the vertebral column (including perhaps because of its proximity to the pelvis) is not permitted to be used for human food (e.g. bone broth/gelatin) since it is highly likely to be seriously contaminated in an infected animal exposed in calfhood. You might consider not permitting recovery of meat scraps from vertebral column. ¹

3.700 The evidence is unclear as to who else received notice of Mr Bradley's views at this stage.

3.701 The memo from Mr Eames, which was sent to Mr Fry, Mr David Taylor and Mr Maslin, drew attention to the danger that Mr Bradley had already identified. ² We consider that the fact that an abattoir had, of its own volition, ceased to use cattle bones to make MRM because of concern that central nervous tissue would remain in the spinal column was a powerful warning that this was a matter to be taken seriously.

3.702 Mr Maslin acted properly in seeking advice in relation to this matter. His suggestion was that because the SBO ban was a measure of 'extreme prudence' going beyond Southwood, 'I assume that we do not wish to get embroiled in further measures on MRM'. ³ But the problem raised in relation to MRM needed to be treated on its merits in the context of the approach that had been adopted of removing from the food chain the high-risk tissues.

3.703 Mr Bradley responded appropriately to Mr Maslin's minute. He warned of the danger that the vertebral column could be contaminated with spinal cord, a risk that he said might be high in infected animals in the late pre-clinical phase. He commented: 'clearly spinal cord must be removed before processing to produce MRM should this be allowed to continue' (emphasis ours). Copies were sent to Mr Lawrence and Mr Meldrum. ⁴

3.704 The consultation process in relation to the SBO ban provided further warning of the danger that the spinal column would be contaminated with residues of spinal cord. Both Ulster Farm By-Products Ltd and the City of Lincoln drew attention to this. ⁵

3.705 These events were enough to put those aware of them on notice of the danger that the spinal column might contain remnants of spinal cord, which would contaminate MRM. Those familiar with slaughterhouse operations should already have appreciated this danger.

3.706 The evidence given to the Inquiry suggests that those familiar with slaughterhouse operations did appreciate this danger. Mr Keith Baker was aware of conditions in slaughterhouses and of the processes for recovery of MRM. Mr Kevin Taylor had not merely served in the past as a DVO in the Meat Hygiene Section, but had been the DVO with responsibility for 'keeping an eye' on MRM. ⁶ Questions then arose as to how much spinal cord would be included in MRM, and whether this would carry sufficient potential infectivity to be of concern to humans. Before turning to those questions, we discuss the separate issue of dorsal root ganglia.

Should the infectivity of the dorsal root ganglia have been suspected?

3.707 At a meeting held by Mr Maclean with representatives of consumer organisations in May 1990, Mr John Godfrey (Member of MAFF's Consumer Panel) tabled the following question on behalf of the Consumers in Europe Group:

Is the risk of infection from nervous tissue limited to material from the brain and spinal cord?

As far as I know the only information we have is on the sciatic nerve, which has only low, though variable, amounts of causative agent in infected animals. In view of the importance of knowing that peripheral nerve does not pose any hazard, a careful study seems urgent. Can one be confident that the nerve cell bodies associated with the dorsal root ganglia are not as hazardous as the spinal column is taken to be? Meat extracted for food from the vertebral column after the spinal cord has been removed as a precaution might well contain dorsal roots. ⁷

3.708 That was, as it transpired, a pertinent question. In 1989, however, the approach to the SBO ban, applying the analogy with scrapie, was to treat as high-risk tissues the spinal cord and brain and the lymphatic system, but not the peripheral nervous system. Mr Bradley told us:

. . . of course there would be nervous tissue in the MRM derived from peripheral nerves which at this time we were not perceiving to be a significant risk factor. Certainly we did not consider dorsal root ganglia at that time which we now know contained detectable infectivity at a late stage of incubation. And we also had no knowledge as to whether these tissues actually got into the MRM. ⁸

3.709 Mr Kevin Taylor commented to us:

I suppose that having decided what the specified offal was, the rest was not specified and we regarded it as low enough risk to go into the human food chain. ⁹

3.710 Dr Kimberlin told us that he might well have expressed the view in 1989 that dorsal root ganglia posed no greater hazard than the nervous tissue that would be present in muscle. The titre would be much lower than that of the spinal cord and the mass of the peripheral tissue would be much smaller. ¹⁰

3.711 Mr Meldrum had a degree of concern about nervous tissue peripheral to the spinal cord, as we shall see at a later stage of the story. Uncertainty about the infectivity of this tissue was an additional reason for concern about MRM, but we do not consider that it should, of itself, have led to an embargo on the practice of recovering MRM from the spinal column.

Was adequate consideration given to MRM when preparing the SBO Regulations?

3.712 Spinal cord had been identified as high-risk tissue that should be removed from the human food chain under the SBO Regulations. The likelihood that slaughterhouse practices would result in portions of the spinal cord, or contamination from spinal cord, remaining after attempts to remove it raised the possibility that the SBO ban might not prove fully effective in practice. It posed a risk to human health if BSE were orally transmissible to humans.

3.713 This risk was particularly acute in relation to MRM. Spinal cord was encased in the spinal column and the vertebrae were the likely repository of any portions of spinal cord that a slaughterhouse operative failed to remove. The spinal column was also the most likely part of the carcass to be contaminated should a spinal cord be macerated in the course of splitting the carcass. The processes of recovering MRM were designed to ensure that any matter that remained attached or adhering to the bones was recovered in order to be used for food.

3.714 The evaluation of the risk posed by remnants of the spinal cord to the safety of MRM required an assessment of two factors:

1. The amount of spinal cord that might be left after attempts to remove it and which might be recovered as MRM.
2. The minimum quantity of spinal cord that might be capable of carrying an infective dose.

3.715 Neither was readily ascertainable.

3.716 To establish the amount of spinal cord that might get into MRM, an investigation was needed into the practical aspects of carcass-splitting and removal of the spinal cord. This needed to have regard to the operating standards prevailing in British slaughterhouses. More sophisticated research involving the weighing of spinal tissue, or the analysis of MRM, was a further avenue that might be explored.

3.717 The question of the quantity of spinal cord that might suffice to infect was a question on which advice needed to be sought from scientists, such as Dr Kimberlin, with expertise in the field of TSEs.

3.718 Neither of the two questions raised above was rigorously addressed in the course of preparing the SBO Regulations.

3.719 In relation to the decision on MRM, Mr Meldrum has stated:

As is clear from events leading up to the introduction of the SBO regulations in November 1989, the issue as to whether action on MRM was required in the context of the SBO ban was raised and considered in the same way as many other issues related to the specified offals were raised during preparation of the regulations (for example, tripe, rennet, casings, bovine eyes, sutures and mesenteric fat). It is axiomatic that the assessment of risk from MRM produced from cattle bones was raised and considered in the context of the ban on the use of certain bovine tissues for human consumption and that consideration was given to the risk to humans from consuming MRM.

3.720 Mr Meldrum misstates the position. The attention that was given to MRM was in stark contrast to that devoted to the specific tissues.

3.721 Mr Bradley carried out detailed studies into each of the tissues under consideration. These studies included visits to manufacturers of tripe, rennet, casings and catgut to examine the effect of manufacturing techniques. Papers were prepared which provided a solid basis for risk evaluation. The results of Mr Bradley's studies were communicated to the DH officials for their consideration.

3.722 So far as MRM is concerned, the picture is very different. Prior to the meeting on 27 September, in an exchange of minutes, Mr Kevin Taylor and Mr David Taylor had agreed that any risk posed by residual spinal cord in MRM would be further reduced by 'dilution'. ¹¹ Mr Kevin Taylor explained that the dilution that he had in mind was that which would have resulted from the 'tiny proportion' of spinal cord that would be left being mixed with all sorts of other perfectly acceptable material to make MRM. ¹²

3.723 Mr Maslin had raised the question of the use of cattle bones in the production of MRM by his minute of 27 July. ¹³ Only Mr Bradley had made a detailed response to this. Mr Meldrum had expressed the hope that 'we will not become involved' in MRM ¹⁴ and Mr Hutchins expressed the view that there would seem to be no justification for a ban on the use of certain bones in MRM production because of fears about the amount of nervous tissue involved. ¹⁵ Mr Hutchins gave no reason for his view and we did not explore this with him. We suspect he was influenced by the terms of Mr Maslin's minute. In the circumstances we would not think it right to criticise him.

3.724 Implicit in these conclusions are assumptions about the size of the dose that would be necessary to infect, were BSE to be transmissible to humans. As to this, Mr Kevin Taylor said:

. . . we did not know the infective dose for humans; we do not now know the infective dose for humans. So it was not anything that could have been considered at that particular time. ¹⁶

3.725 It does not seem to us that these expressions of view by Veterinary Officers in the Meat Hygiene Division represented, of themselves, an adequate process of risk evaluation. The SBO ban set out to exclude from the human food chain the brain and spinal cord as tissues in the highest risk category. Once it was concluded that it would not be possible in every case to remove the entirety of the spinal cord from the spinal column, a process which would ensure that any residual spinal cord was harvested from the spinal column and used for human food required the most careful, informed scrutiny by the policy-makers. There was no valid basis upon which it could be assumed that if a portion of spinal cord ended up in MRM it would carry no significant risk of infectivity.

3.726 MRM was discussed at the meeting on 27 September. The issue arose because of the responses to consultation of Ulster Farm By-Products Ltd and the City of Lincoln. Mr Martin told us that he only received copies of these responses when he arrived at the meeting. ¹⁷

3.727 We have set out the contemporary records of what was said about MRM at the meeting at paragraphs 3.592-3.593. Witnesses were not able to add significantly to these accounts from recollection. Mr Martin, Deputy CVO at DANI, summarised the position as follows:

What we were trying to do here was try to put what we thought at the time was a fairly small risk . . . into context and draw a line somewhere, do a risk analysis on it and draw a line. And I think the conclusion of the meeting as recorded there was that this was such a small risk it was completely negligible . . . ¹⁸

3.728 Mr Cruickshank, who chaired the meeting on 27 September, dealt with the position in a statement:

In relation to action on mechanically recovered meat, it should be remembered that the scientific advice was that the proposed offals ban was not in any case necessary to protect health. In going beyond this advice MAFF exposed itself to the risk of a challenge on grounds of disproportionality. This risk would have been greatly increased if we had banned products where the degree of risk was particularly low. The advice of the MAFF veterinarians, which was accepted by the Department of Health, was that it was most unlikely that any BSE agent would be present in MRM.

Mr Martin's comments about the illogicality of what was proposed on MRM were made in the context of a discussion where I think all present were conscious of the risk that, given the lack of scientific knowledge of BSE, virtually any part of our proposals taken in isolation could be challenged as illogical. This was not a reason for not proceeding - it simply meant that we had to be very careful to ensure that the package as a whole was so far as possible internally consistent and reasonable. Mr Martin's oral evidence to the Inquiry indicated he agreed with the conclusion that the risk from MRM was 'completely negligible'. ¹⁹

3.729 When he returned to give oral evidence in Phase 2 he said that he did not specifically recall anyone saying that there would be bits of SBO going into MRM: ²⁰

We were in the position, as with so many of these issues, where you could not make calculations and draw lines; you had to rely on people's judgement. The veterinary judgement was that mechanically recovered meat was acceptable. ²¹

3.730 Mr Kevin Taylor emphasised in oral evidence and in written statements that he had no responsibility for either the human SBO ban or the use of MRM as these matters related to human, as opposed to animal, health. He believed that responsibility for advice about the need to protect human health by preventing the consumption of particular animal tissues lay with DH, even if the necessary legislative action was then taken by MAFF. In any event, his responsibility was to advise on the implementation of those recommendations involving live cattle. ²²

3.731 Mr Taylor had no recollection of the meeting on 27 September. He suggested that the concern raised related not to leaving spinal cord behind, because by definition it should have been removed, but to the danger of causing contamination by damaging the spinal cord while splitting the carcass. ²³ He said that he was reasonably content about MRM because when he accompanied foreign veterinary teams to British slaughterhouses, the SBO was being properly removed. ²⁴

3.732 Like Mr Taylor, Mr Lowson emphasised that his Divisional responsibilities were restricted to animal health.

. . . I had no responsibility for considering the safety and fitness for human consumption of MRM derived from bovine carcasses. ²⁵

3.733 In relation to the 1989 Regulations he stated that they were made under the Food Act and that the Meat Hygiene Division had taken the lead in preparing them, in accordance with that Division's normal responsibilities and Mr Cruickshank's decision about how responsibilities for work following up the ministerial decisions of June 1989 should be divided. ²⁶

3.734 Mr Lowson pointed out that the meeting on 27 September was attended by Mr David Taylor, who was at that time a senior veterinary surgeon dealing with meat hygiene issues, and Mr Kevin Taylor.

These were the veterinary experts . . . who were familiar with slaughterhouse practices on whose advice it was necessary to rely on issues such as this. ²⁷

3.735 Mr Lowson could not recall the details of the discussion at the meeting, but said that he believed that he would have been impressed by the fact that there would be:

. . . a requirement to remove the specified offals themselves, so that for example in the case of greatest relevance to MRM, the spinal cord should be removed before the bones of the spinal column were used to harvest mechanically recovered meat. So, even if that were not done perfectly, a large amount of the potentially infective tissue would be removed from the process.

. . . the major step in reducing risk was to remove these materials or to require these materials to be removed at the slaughterhouse . . . The question is: do you add to any worthwhile extent to the additional safeguard that you have taken beyond what Southwood recommended . . . ²⁸

3.736 Mr David Taylor attended the meeting on 27 September to deputise for Mr Keith Baker, his superior. ²⁹ Mr Baker was referred to the fact that in 1995 it was calculated that on average spinal cord was being left in carcasses in about 4 cases in every 1,000. He said that that was not a statistic which surprised him:

. . . there would be occasions when you might get a bit of bridging of the spinal canal and you could potentially have a small piece hidden within that bridging of the spinal canal. Not very common but it could happen. ³⁰

3.737 Mr Baker said that in 1989 he would not have thought that this quantity of spinal cord would be critical. His perception changed later when he learned that a small oral dose was sufficient to infect cattle. ³¹ He made the point, however, that it was not for his section to advise on the implications that this might have for the safety of MRM:

The specific question of MRM and its safety for human consumption was concerned with 'what constitutes an infective dose?' I, and those who reported to me, had no involvement whatsoever in those considerations. ³²

3.738 When he saw the minute of the meeting on 27 September he did not consider that it was his role to consider the reasoning that had led to the conclusion that the nervous tissue contained in MRM would be minimal and would not present a significant risk. ³³

3.739 Mr Meldrum has emphasised repeatedly to us that as CVO he was not responsible for human health. That was the responsibility of the CMO. More particularly, consideration of what might be the infective dose for man was 'quite properly the responsibility of the Department of Health and not MAFF'. ³⁴ So far as the human SBO ban was concerned, his discussions with DH related to where you drew the line on which tissues should go into the SBO ban 'bearing in mind . . . that the response from the Department of Health initially to this was somewhat lukewarm'.

3.740 We accept that the ultimate responsibility for risks posed by food to human health lay with DH. Dr Pickles also accepted this when it was put to her. ³⁵ But she made the point that the assessment of risk to human health was a matter for both Departments, working very closely together, and some of the risk management strategies were a matter for MAFF. ³⁶

3.741 So far as the human SBO ban is concerned, MAFF was in the driving seat. The ban was being introduced on the initiative of its Minister. DH was, as Mr Meldrum has pointed out, lukewarm about the ban. MAFF, and the Animal Health Division in particular, was taking the initiative in proposing the policy decisions as to what should be covered by the ban. This was being done in consultation with DH, but Dr Pickles, Dr Metters and Sir Donald Acheson were taking a back seat in the exercise.

3.742 The decision as to what should be included in the ban involved an exercise in risk evaluation and management. The risk in question was risk to human health. MAFF could not perform the exercise in which it was involved without considering risk to human health. Our approach is to consider whether MAFF officials and Ministers gave adequate consideration to the risk to human health when deciding upon the ambit of the SBO ban. The same consideration has to be given to DH, which shared responsibility for the decisions, albeit that it was playing a minor role.

3.743 The respective roles of the two Departments were made quite clear by the terms of the submission to Mr Gummer drafted by Mr Lawrence. The only reference to DH in this was the following:

The Deputy Chief Medical Officer has endorsed the measures proposed in paragraph 5 and could accept an exclusion for calves under six months of age. The same view was taken by Sir Richard Southwood and Dr David Tyrrell, who chairs the Consultative Committee on research. ³⁷

3.744 In a statement to the Inquiry, Mr Meldrum said:

So far as MRM is concerned since knowledge of the production systems lay with MAFF it was not unreasonable for the Department of Health to rely upon MAFF for technical advice, as it did in many other situations, and for MAFF to offer advice to the Department of Health. ³⁸

3.745 We are in no doubt that MAFF's role in relation to the introduction of the SBO ban involved a responsibility to give consideration to the question of whether MRM should continue to be produced from the spinal column of cattle carcasses and to advise DH accordingly.

3.746 The decision on MRM depended critically on a combination of knowledge of the processes of carcass-splitting and removal of the spinal cord, knowledge of the processes of extracting MRM, knowledge of standards of operation, inspection and monitoring of abattoirs and an understanding of what was known, and what was not known, about infective dose in relation to TSEs.

3.747 No one before the meeting on 27 September set about collecting this information and presenting it in a form that would enable an informed policy decision to be taken. There appears to have been a general assumption that, if any spinal cord were to get into MRM it would do so in quantities too small to represent a threat. Some failed to appreciate the extent to which spinal cord might get into MRM. Some seem likely to have made unwarranted assumptions about the minimum effective dose.

3.748 The inadequacy of the consideration that was given to MRM in 1989 is demonstrated by the extent of the work that proved necessary in the following year in order to prepare a paper on this topic to put before SEAC.

3.749 What would have happened if MRM had received proper consideration at the time of preparation of the SBO Regulations? There would have had to be the kind of investigation within MAFF that took place in the following year in the course of preparing the paper for SEAC's consideration (see Chapter 4). This would have been likely to lead to the conclusion that there would on occasion be contamination of the spinal column with spinal cord as a result of carcass-splitting.

3.750 Consideration would have had to be given to the amount of spinal cord that could carry an infective dose, should BSE be orally transmissible to humans. Expert assistance would probably have been sought in relation to this - perhaps from Dr Kimberlin. The exercise would have been speculative and would probably have involved consideration of Hadlow's work. We believe, however, that the conclusion would have been reached that a small piece of this potentially highly infective tissue might suffice to carry the minimum infective dose. In this context we note the comment of Mr Bradley in relation to the paper prepared for SEAC in the following year: A gram of infected cord could have a lot of infectivity. ³⁹

3.751 Options would no doubt have been put forward, as they were initially in the paper prepared for SEAC. These options would have received consideration, initially by Mr Meldrum, subsequently, together with Mr Meldrum's conclusions, by Dr Pickles and Dr Metters and ultimately perhaps, with recommendations, by Mr Gummer and Mr Maclean.

3.752 It is possible that the decision would have been taken to prohibit the use of the spinal column for the extraction of MRM. Such a course would, however, have met strong opposition from the producers of MRM affected by it. Mr Meldrum, to judge from his reaction the following year, would have been likely to consider it disproportionate. In evidence to us, he said:

At the time of discussions in late 1989 I believed MAFF had gone as far as was possible on the evidence available at the time in moving away from the initial advice on baby food that was contained in the Southwood Report to the introduction of the SBO Regulations. ⁴⁰

3.753 Mr Cruickshank also emphasised to us the concern of MAFF officials at the possibility that the SBO Regulations might be the subject of successful judicial challenge:

In relation to action on mechanically recovered meat, it should be remembered that the scientific advice was that the proposed offals ban was not in any case necessary to protect health. In going beyond this advice MAFF exposed itself to the risk of a challenge on the grounds of disproportionality. This risk would have been greatly increased if we had banned products where the degree of risk was particularly low. ⁴¹

3.754 This concern was realistic. When, in 1995, the use of the spinal column as a source of MRM was finally prohibited, the economic effect on one manufacturing company was sufficiently great for it to seek leave for judicial review. ⁴²

3.755 In the circumstances, we think that it is unlikely that closer scrutiny of MRM in 1989 would have resulted in a decision at this stage to ban recovery of MRM from the spinal column. The more likely decision would have been that the importance of the total removal of the spinal cord should be emphasised to slaughterhouse operators and to local authorities, and that the degree to which this was achieved once the SBO ban was in force should be carefully monitored.

3.756 Had such a course been adopted, we do not consider that it would have been open to criticism. It would have been likely to have led to a review, such as that which was to take place in the following year, as a result of the reports from local authorities of the difficulty of total removal of the spinal cord and of the disquiet expressed from a number of quarters in respect of the risks posed by MRM. These are considered in the next chapter.

3.757 As MRM was revisited for more thorough consideration in the following year, the question of why it received inadequate consideration in 1989 is of limited significance. We believe that the root of the problem lay in the division of responsibility in relation to the introduction of the SBO Regulations.

3.758 The Meat Hygiene Division considered that its role was simply to be responsible for the drafting of the Regulations. Policy decisions as to what should go into them were for the Animal Health Division. For the most part this worked well. Decisions on which tissues should be included in the ban were appropriate decisions for AHD, with the assistance of the CVL.

3.759 The potential risk posed by MRM called, however, for consideration by those in the Meat Hygiene Division with knowledge of slaughterhouse conditions and practices and of the extent to which the spinal column was likely to contain portions of spinal cord, or to be contaminated with this as a result of the process of carcass-splitting. This does not appear to have received vigorous consideration.

3.760 The question of the risk posed by MRM was raised by Mr Bradley with Dr Watson in April (see paragraph 3.699). It was raised again by Mr Maslin in July (see paragraph 3.702). On neither occasion was detailed consideration of the issue provoked. It was raised again at the meeting on 27 September where the minuted decision was that no action should be taken on MRM because the nervous tissue that it would contain would be minimal and pose no risk. That conclusion was questioned by the Ministers, who received reassurance from Mr Lawrence and Mr Meldrum. So far as peripheral nervous tissue was concerned, this reassurance appears to have been founded on advice from Dr Kimberlin. So far as contamination from the spinal cord was concerned, Mr Meldrum told us that he relied upon the conclusion reached at the meeting on 27 September. ⁴³

3.761 Consideration of the proposed SBO Regulations was a team exercise and the failure to give rigorous analysis to MRM was a team failure. We believe that this failure is explained in large part, and mitigated, by the general belief that the SBO ban was a measure of extreme caution that went beyond the recommendations of the scientists. In the circumstances it is easy to understand the reaction that if there was a failure on occasion to remove a little bit of spinal cord, this was unlikely to matter. This does not, however, excuse the failure to carry out the rigorous risk evaluation that was required in order to reach a sound decision on policy.

3.762 We have grave concerns about the outcome of this meeting in relation to MRM. We feel that the problem posed by MRM should not have been dismissed at the meeting of 27 September 1989. It should at least have been identified as calling for further consideration. However, no witness could remember any relevant detail as to the information or views contributed on this subject at that meeting. It would not, in these circumstances be fair to criticise any individual for the conclusion that was reached. Nor would it be fair to criticise those who placed reliance on that conclusion. We simply are not in a position where it would be fair to allocate blame to any individual for the failure to give rigorous analysis to MRM in 1989.

Consideration of MRM by DH

3.763 The meeting of 27 September was called at short notice, and Dr Pickles was unable to be present. She received Mr Maslin's note of the conclusions of the meeting. ⁴⁴ In a statement she said this about MRM:

On this highly technical issue I would have expected one of MAFF's officials to raise with me any specific concerns which they may have had in relation to MRM, about which, unsurprisingly, I knew very little. I was aware from the Minutes of the meeting held in MAFF on 27.9.89 that MRM had been considered and that the many officials attending the meeting had determined that as only a minimal amount of nervous tissue would be contained in MRM, there was no need to take any action on it. I would have been prepared to accept that the presence of a small amount of tissue was consistent with the ALARP principle of risk assessment and so, having read this, I would not have been prompted to take the matter any further. ⁴⁵

3.764 Dr Pickles told us that she was not familiar with MRM. She said:

I would have thought if there was genuine concern in MAFF about mechanically recovered meat and what was in it, I would have expected a memo to come to me asking me specific questions. I did not see that. I have to say on mechanically recovered meat again I read with some interest some of the papers within MAFF in the following year. I noticed there was a lot of debate about it. I also notice none of those papers were copied to the Department of Health. ⁴⁶

3.765 Dr Pickles added:

I would have thought if I had known nervous tissue was getting into mechanically recovered meat, that might have actually influenced whether we recommended action should have been taken on that. ⁴⁷

3.766 Dr Metters's statement followed similar lines to that of Dr Pickles. ⁴⁸ In oral evidence he explained that he had understood MAFF's concern about MRM to relate to peripheral nervous tissue. DH had already made it plain that it did not want any spinal cord going in. He said:

. . . if I knew then what I now know about mechanically recovered meat, I would have taken a different view. At that stage I think there was insufficient clarity in the descriptions of MRM that were given to the Department of Health. Had we known the process of what was going on we might have taken a different view. But looking back at all the contemporaneous documents, we were insufficiently knowledgeable and insufficiently informed. ⁴⁹

3.767 The comments of Dr Pickles and Dr Metters serve to underline the point that the approach of MAFF officials to MRM differed from their approach to the identification of the tissues which were to be subject to the ban. DH was given no notice of the concerns which had been raised about MRM other than the short reference to this in the note of the meeting of 27 September. We do not consider that Dr Pickles and Dr Metters are open to any criticism for accepting MAFF's conclusion that the nervous tissue in MRM would be minimal and not present a significant risk.

3.768 At the same time we would observe that, had Dr Pickles or Dr Metters been persuaded at this time of the importance of the SBO ban they might have been more closely involved in the consultative process. This back seat role followed from the failure of DH to carry out a proper review of the Southwood Report.

The Ministers' decision

3.769 Mr Gummer and Mr Maclean explained to us their reason for expressing concern about MRM and the ban (see paragraphs 3.597-3.598). This was stimulated by consumer concerns about whether this product should properly be described as 'meat', which had led the Ministers to become familiar with the process and with the fact that the product was somewhat unattractive. ⁵⁰ It was this general consideration which led Mr Gummer to refer to MRM as being 'presentationally more difficult'. ⁵¹

3.770 Mr Maclean, mindful of his new role as Food Safety Minister, raised a number of searching questions in relation to MRM when he received the submission of 4 November. ⁵²

3.771 On 7 November any concerns that the Ministers entertained about MRM were assuaged by Mr Meldrum. Mr Meldrum knew that MRM had been considered at the meeting on 27 September. There were present at that meeting veterinarians with greater knowledge of slaughterhouse practices and MRM than Mr Meldrum. We do not consider that Mr Meldrum can be criticised for accepting the conclusion reached at that meeting and advising Ministers accordingly. He explained to us that he did not believe that the spinal cord ruptured when cut and that he would have explained to Mr Maclean that the problem of cutting through could be addressed by careful removal of any fragments at the dressing stage. Most of the discussion related, however, to the significance of peripheral nerves in the spinal column, which would be liable to be sucked into MRM. Dr Kimberlin confirmed to us that he could well have advised MAFF that the risk from these would be quite small. ⁵³ We think it likely that this explains Mr Lawrence's reference to Dr Kimberlin's advice.

3.772 We consider that the Ministers are to be commended for questioning the submission that they had received in so far as it related to MRM. Had this matter been fully explored when preparing the Regulations, we do not believe that Mr Meldrum would have been in a position to give quite so reassuring advice about the consequences of cutting through the spinal cord.

Enforcement

3.773 MAFF officials did their best to get representatives of the local authority organisations to attend a meeting to discuss the SBO Regulations. It is perhaps indicative of the significance attached to the Regulations that only the IEHO attended the meeting on 18 October. The understanding of Mr Lawrence and his colleagues was that the new Regulations would impose little additional burden on those who were already responsible for the enforcement of the Meat (Sterilisation and Staining) Regulations, other than some additional paperwork in relation to the issue of movement permits. The local authority organisations may well have taken a similar view.

3.774 There was one vital piece of advice that needed to be given to the local authorities. They should have been told that it was essential that the entirety of the spinal cord was removed from the carcass and that meat should not be stamped as fit unless this had been done.

3.775 This advice was never given. No doubt many Meat Inspectors reached this conclusion for themselves, but we do not believe that it would have been obvious to all. Remarkably, as late as 1995, there was debate in the context of the operation of the new Meat Hygiene Service as to whether a Meat Inspector could refuse to stamp a portion of a carcass on the ground that it contained residues of spinal cord. ⁵⁴ The belief that 'a little bit cannot matter' may well have been widely shared.

3.776 Mr Lawrence was initially responsible for communication with the local authorities about the implementation of the new Regulations. We do not consider that he should be held at fault for failing to emphasise the importance of total removal of the spinal cord. He was carrying an immense administrative burden at this stage. In the absence of advice on this matter from his veterinary colleagues, we do not think that he could have been expected to focus upon this matter of his own initiative.

3.777 The understanding of the administrators of the effect of the Regulations is illustrated by evidence given to us by Mr Duncan Fry, Head of Group C in the Meat Hygiene Division:

There were no or very few additional procedures or activities which had to be undertaken to fulfil this plan, as far as I can recall. The carcasses were already being split so the spinal cord thing was not a problem. They were opened, offal was removed. Intestines were removed. Everything was being done already. The only change in procedure was that some things were being condemned rather than going on through. ⁵⁵

3.778 By the same token, when the SBO Regulations were introduced, no instructions were given to the veterinarians in the Veterinary Field Service, who made periodic visits to slaughterhouses to monitor compliance with regulations, that it was important to check that all spinal cord was being removed from carcasses.

3.779 The failure to take any specific steps to encourage strict compliance with the obligation to remove the spinal cord is not one for which we allocate blame to any individual. It was, it seems to us, closely allied with the failure to appreciate and address the MRM problem. There were at the time some who knew the nature of operating conditions in slaughterhouses and the difficulties that there would be in effecting complete removal of every spinal cord. There were some who would have been able to advise that the potential infectivity of spinal cord was such that a small portion might suffice to infect. The failure to carry out a rigorous analysis when questions were raised about the practicality of the implementation of the ban on spinal cord and the safety of MRM resulted in a communication failure. The two strands of knowledge were not brought together.