Volume 6: Human Health, 1989-96
4. Human health developments:January - December 1990
Slaughterhouse practices and MRM
Discussion

Discussion

Introduction

4.296 We have observed that the problem of contamination of MRM by residues of spinal cord did not receive the attention that it deserved when the SBO Regulations were being prepared. MAFF Ministers and officials did not, however, lose sight of the problem. As Mr Lowson observed:

There was concern about this issue within MAFF through 1990 and a brisk debate during 1990. ¹

4.297 We propose to analyse the consideration that was given to MRM in 1990 in some detail. This is because we believe that the extraction of MRM from bovine vertebrae was the most likely route by which SBO may have entered the human food chain. In a letter to Dr Pickles dated 17 June Mr Bradley observed:

The public perception is that the offals ban is an important protective mechanism against exposure. If that is not the case we need do no more - but if it is, improving it will be necessary as there are chinks in the armour. ²

4.298 We believe that MRM was a major chink in the armour. The consideration that was given to MRM in 1990 did not lead to the blocking of that chink. We have sought to identify why that was.

4.299 It is perhaps helpful, at the outset, to set out in a nutshell what occurred. MAFF officials correctly identified that the slaughterhouse operation of splitting the carcass down the spinal column was an operation which would inevitably, on occasion, damage the spinal cord and result in contamination of the carcass, and in particular the spinal column, with residues of spinal cord. This was of particular significance in that the spinal column was the major source of bovine MRM. SEAC was provided with a lengthy paper which advised it of this and of many other matters, and asked to advise generally on whether any action needed to be taken. After slaughterhouse visits SEAC concluded that, if proper procedures were followed, the spinal cord could be removed without difficulty. SEAC then advised that, provided that 'the rules were properly followed and supervised', no further measures for consumer protection were necessary. SEAC's advice was treated as giving a clean bill of health to current practices and procedures. SEAC's proviso was assumed to be satisfied. No steps were taken to address the problem of contamination of MRM until 1995, when an audit of slaughterhouse practices disclosed that the spinal cord was not always removed cleanly and totally in the slaughterhouse.

4.300 We start by considering the extent to which there were in fact failures to remove spinal cord in 1990. For this purpose we need to review evidence covering 1991-95 as well. We then turn to consider the course of events in 1990 in more detail. A detailed description of events covering MRM from 1991 onwards is given in chapters 5 and 6.

Standards of removal of spinal cord

4.301 Members of the Veterinary Field Service (VFS) made regular visits to slaughterhouses to monitor compliance with statutory regulations which included the human SBO ban. Returns of the results of the inspections were made to the Meat Hygiene Division at Tolworth. Many of these returns have not been preserved. We shall see shortly that in 1990 there is one record of a MAFF veterinarian noting incomplete removal of spinal cord in two sides of beef. We are not aware of any other instance where there was a report of failure to remove the whole of the spinal cord until 1995, when a significant number of such failures was reported.

4.302 Either standards of removal of spinal cord deteriorated in 1995 or the monitoring of the SBO ban which was carried out by the SVS between 1989 and 1995 failed to disclose the shortcomings that were occurring. We are in no doubt that the latter is the true position. We propose at this stage to review the evidence which satisfied us that there was, throughout this period, a continuing failure on the part of those employed in slaughterhouses to ensure that the entirety of the spinal cord was removed from carcasses before the health stamp was applied.

4.303 We had evidence about this from many sources and it was not entirely consistent. The efficacy with which the spinal cord can be removed depends upon the skill of the operative and the type of saw used. The following selection of the evidence makes it plain that there were many occasions on which the spinal cord was not cleanly removed.

4.304 The immediate response of EHOs to the new Regulations was summarised in a lengthy letter from the IEHO to the MAFF's Animal Health Division. This recorded:

In practice the spinal cord is often shredded and fragmented by the mechanical carcass splitting saw, not only contaminating the meat but also prohibiting effective removal as per the Regulations. ³

4.305 Mr Trevor Higton had experience as a licensed slaughterman, a local authority meat inspector and a meat hygiene inspector with the Meat Hygiene Service. ⁴ He gave us this description of the operation:

The normal process is to saw straight down the centre of the spinal canal, which effectively cuts the spinal cord itself in half. The saws that are used in normal operation are, because of their nature . . . water cooled, the blades are water cooled so there is spray without doubt, there is contamination of surfaces. It is, from what I understand it is unavoidable. ⁵

4.306 Mr Ron Spellman had worked as a local authority meat inspector for a total of 28 years before becoming a meat hygiene inspector with the Meat Hygiene Service. He gave us this description:

. . . as the person operating the saw comes down the spine, they are extremely unlikely to stay on one route. Just deviating by a few centimeters to the left to right, they will tend to cut through. You may well see in an abattoir . . . a cord which is whole meninges complete for several feet and then a couple more feet may be on the other side where the saw has gone through. You may have sections of spinal cord, but they will be whole on this side, then whole on the other side. ⁶

4.307 Mr Spellman gave this description of how techniques had changed under the Meat Hygiene Service, which was established in 1995:

The situation we had then was the spine was split down the middle and an operative would make an attempt to remove the spinal cord. We now know that . . . if the whole meninges and all the soft fat behind the meninges are not removed, so effectively you are looking at just bone, a canal of bone, it is almost impossible to be sure that all spinal cord has been removed.

We went through a series of processes really from November probably until the spring of 1996 where gradually the MHS toughened the controls on the slaughterers to achieve this. We did not go immediately to that stage. Under the old system if the spinal cord is just pulled out and the meninges and the soft fat left behind, an inspector running his knife down the canal will often see slivers of cord pop out. It was extremely difficult to be sure that 100 per cent compliance was achieved at that stage. As I say it is now necessary to have virtually a completely clear canal of bone to be sure that you are in the 100 per cent category. ⁷

4.308 Mr Spellman also spoke of 'problems with areas of spine left bridged over where the spine was not properly sawn down the middle'. ⁸

4.309 Mr William Swann, leading one of a number of Hygiene Assessment Teams for the Meat Hygiene Service in 1995, visited over 90 slaughterhouses. He told us that he saw very little evidence of serious damage to the spinal cord. ⁹ He said, however, that in the smaller abattoirs where equipment was less maintained or less modern, and perhaps because operatives were less skilled, the saw deviated off the mid-line when the carcass was being split so that there would be a section where the spinal cord would not be visible and removal was not complete. ¹⁰

4.310 Mr Swann had kept his contemporary notes and told us that a large number of them referred to spinal cord still being present in carcasses after meat inspection. He commented that this was a direct route of potential entry of spinal cord into MRM. ¹¹

4.311 Ms Marja-Liisa Hovi, who worked in an abattoir as a designated OVS, confirmed evidence given by Mr Swann that maceration of the spinal cord was not very likely. She added that she agreed with him that bits of spinal cord were often left on the carcass after the health mark was stamped on it:

It often was the bits of spinal cord were left on the carcass in cases where the saw had actually cut the spinal cord in small pieces, or the saw perhaps had not gone straight through the middle and pushed the spinal cord on its way, where it had perhaps gone in at a bit of angle and cut it off so the spinal cord did not come off when the operator removed it with the hook, and they usually just removed the bit that came out and left the bits that were cut off by the saw. In my opinion that was usually the case, of leaving bits of spinal cord in the spinal cavity. ¹²

4.312 Mr Andrew Fleetwood (SVO, SVS, 1991-96), ¹³ concerned with monitoring the enforcement of the SBO Regulations in 1995, said this about the operation of removing the spinal cord:

Bovine carcass at this time were split lengthways by a power saw down the vertebral column. It requires an extremely skilled operator to split the carcass absolutely in half down its entire length. In most cases the saw will deviate by only a few millimeters to one side or another. The consequence of that is that spinal cord can become slightly concealed in that portion of the spinal column where the saw has not been absolutely transversely through the middle. ¹⁴

4.313 He added:

In a busy production slaughterhouse, spinal cord removal will not be complete at the time of splitting the carcass in a small number of cases. That is understood and acceptable but obviously all fragments must be removed before the animal receives a health mark. ¹⁵

4.314 Mr Johnston McNeill (Chief Executive, Meat Hygiene Service since April 1995) gave us further evidence in relation to the problem posed by the meninges:

. . . we were concerned that the procedure of leaving the meninges, which is the fatty tissue surrounding the spinal cord - that the procedure that was recommended, or was normal practice, required that that should be left; which was a difficulty for our staff because when the carcass was split it was quite possible that thin slivers and small slivers of spinal cord could be tucked in between the spinal column itself and the meninges.

That made things rather difficult for our staff in that later, when that carcass went into the chill and that contracted, these little slivers could become visible then, whereas they may not have been visible at the time of inspection of the carcass when, of course, it is warm. And that was an area that I know Peter [Soul, MHS Director of Operations] had discussions with the vets at Tolworth, about the possibility . . . that the meninges should be removed in its entirety, so as to ensure that these incidents did not arise. ¹⁶

4.315 This evidence demonstrates that clean removal of the spinal cord depended critically on the way the operation of sawing the carcass in half was effected. There were inevitably going to be occasions upon which the spinal cord was not cleanly removed.

4.316 We note here that Mr Colin Maclean of the MLC told us that:

Periodically, the Government, MAFF, had a Fatstock Inspectorate which was a small cadre of skilled people in this area who would go and inspect our [MLC] inspectors, so they would audit what they were doing and they would produce infringement reports so that if they went in and said 'We found too much kidney in the channel fat', they would write a letter and say: 'Naughty boys, discipline your troops', which is then what happened. I think, Chairman, as you have seen from our input to you, we, in 1990, out of the thousand reports, found one infringement thing associated with spinal cord which reassured us because it said the mechanism was working and clearly therefore we believe on balance that the majority of the spinal cords at that period of time would be out of the animals in the factories we were in. ¹⁷

4.317 Although the Fatstock inspections suggested that spinal cord was being removed, Mr Maclean indicated that one had to be aware of the realities:

. . . when you are talking about somebody saying, 'You will do a biological control to 100 per cent', those of us who are informed know it does not mean that. It does not mean there is no afferent nerve sitting there with a bit of spinal cord stuck on it, of course it is. And therefore you had to be satisfied that the assurances you were giving took that into account. ¹⁸

4.318 Finally, we would refer to the evidence given by the representatives of three of the major retailers. They told us of the results of inspections that they carried out for quality assurance purposes at the abattoirs that supplied them. On occasion they found that the stripping out of the vertebral column was not being done as efficiently as it should have been and they raised this matter with the relevant management in the abattoirs. ¹⁹ This evidence was of particular significance as the suppliers to these supermarkets would have been selected from the upper end of the slaughterhouse industry.

4.319 We turn next to consider whether, in the period from 1989 up to 1995, there was a failure on the part of the meat inspectors employed by the district councils to ensure that, where spinal cord had not been removed by the slaughterhouse operatives, the offending portions of spinal cord were removed before the carcass was health stamped.

4.320 Mr Swann told us of occasions on which meat inspectors were found to have stamped carcasses which contained spinal cord after the Meat Hygiene Service took over the task of inspection from local authorities. We do not believe that this was a new phenomenon. The meat inspectors were the same people; they had simply switched employment from local authorities to the Meat Hygiene Service.

4.321 We mentioned in paragraph 4.85 the report by Mr Webster of 20 November 1990. Among other things, he found evidence that meat inspectors at one slaughterhouse had not noticed two bovine carcasses containing remnants of spinal cord. ²⁰

4.322 Mr Christopher Clark (Meat Hygiene Inspector and Hygiene Advice Team Officer, Meat Hygiene Service, April 1995 to March 1996) ²¹ told us that when the SBO ban was introduced staffing levels were not good enough to check on things like the ban. ²²

4.323 Mr Spellman drew attention to the contrast between the situation when the Meat Hygiene Service took over and the position a year later after controls had been improved.

The situation was very difficult in the autumn of 1995. Inspectors attempting to achieve 100% compliance with spinal cord removed were under tremendous pressure. They had insufficient room normally and insufficient staff.

If we look at what has happened in the interim, it now becomes apparent just how difficult the task is to achieve 100% compliance . . .

. . . There are more staff on the line, both plant staff to achieve the necessary presentation of the carcass and there are more inspection staff on the line to make sure that the regulations are complied with. ²³

4.324 Mr McNeill told us that at the time the Meat Hygiene Service took over there had been a concern from the industry that meat inspection levels varied substantially throughout the country. ²⁴ Initially there was a notional allocation of the time the meat inspectors devoted to SBO work of 15 seconds per animal. ²⁵ This proved inadequate and an additional 300 meat inspectors had to be employed by the Service. ²⁶

4.325 Mr Peter Soul told us that when the Meat Hygiene Service took over they found a lack of compliance with the SBO Order on the one hand and a lack of enthusiasm for enforcing the Order on the other. He explained:

. . . when you split a carcass, if you get it right down the mid-line it is easy to remove the spinal cord but if you go slightly off centre, a piece of the spinal cord is trapped in the canal and is difficult to remove, and it is then quite a business to have to take the carcass back and either split open the canal with an axe or take it back to the saw, and this slows down the line and slows down production and so on. So if you are enforcing your order rigorously you have to make sure that that is done, whereas I think the feedback that was coming through at that time was that, you know, if that happens then nobody would have been particularly bothered about it. That side of beef would have gone through with that little piece of spinal cord still left in the vertebral column. ²⁷

4.326 We had evidence from EHOs of the pressure that meat inspectors could find themselves subjected to in an abattoir. Dr Joseph Gracey (President, Humane Slaughter Association and Council of Justice to Animals and author of Meat Hygiene, a comprehensive guide for meat inspectors) told us that the environment in an abattoir could be very stressful for the meat inspector. Some had to put up with not only verbal abuse but also physical abuse. Not all the meat plant owners were agreeable individuals. The speed of operations, the speed of the slaughter itself, put pressure on inspectors without the ability to do the task properly. ²⁸

4.327 Finally, we would quote at length from a summary given to us by Mr Lawrence of what he learned as head of a project team set up in October 1992 to establish the Meat Hygiene Service:

What it revealed was that there were well over 1,000 meat inspectors out there working for, as commented, over 300 local authorities. Some were full-time, some were part-time.

There were EHOs, some employed OVSs, official veterinary surgeons, but many on contract and there were also a number of contract meat inspectors. So with that we had a global picture. The next stage for us was to actually go out there and talk to these people to see how they managed the operation.

During the course of I suppose over a year, we visited over 35 individual local authorities to discuss the way they managed the operation. Those discussions were with chief environmental health officers, EHOs, meat inspectors at the plants, OVSs. So we covered the range, we covered the ground, and we talked to very many people.

We also met organisations such as the Association of Meat Inspectors and the Veterinary Public Health Association where we were able to talk to them in groups, again to get their views and opinions about the operation under the local authority system and what they felt about the establishment of the Meat Hygiene Service.

The results of that were very interesting and they were very mixed. There were some excellent, I think, local authorities, well-managed; others, it was not the case. I wanted to just point out some of the problems that we found as a project team in talking to individuals. In many cases, there seemed to be an unclear management chain. Meat inspectors did not seem to know who to report to. If they wanted advice on personnel matters, who were they to go to? Ostensibly it was the EHO, but he was often quite a long way away working in the council offices. Most of the OVSs were on contract and again there were problems about the working together, if you like, between the OVS and the meat inspector. In other words, in many plants there did not seem to be any team work. The meat inspectors did not respect the OVS and vice versa.

In some cases, there was animosity between plant management and inspectors. In a few cases there was actual intimidation. I think that has been borne out by some of the press reports I have seen in the Meat Trades Journal very recently, but that was a problem.

In one or two instances we felt that the plants actually had influence over the local authorities. If a plant was in financial difficulty and that plant had a large number of employees working locally, then the closure of the plant could have meant loss of jobs. I think that may have impacted on the attitude of the local authority to the work that they were undertaking in those plants. Meat inspectors wanted more training and they wanted wider experience in other plants. In many cases, it was not possible.

A lot of authorities only had one plant. They were only responsible for one meat plant and there may only have been two or three meat inspectors. There were really no prospects for these people, so there was a lack of motivation.

In those circumstances too there was a danger of familiarity if they spent too long in one plant in a small authority, and also the potential to get stale. Another thing that we found was that there were in some cases a lack of coordination between local authorities. We actually came across this at a plant visit when there was an allegation of unfit meat and, of the two plants involved, one plant was in another authority and these two authorities did not get on very well. So there was a difficulty there about coordinating the activities.

There did not seem to be any consistency on guidelines for enforcement. Some seemed to be very good, very tidy and well understood by all the people on the ground; in other cases, that did not seem to be the case at all. I think there was a general feeling of isolation. Again, those characters who worked in one single plant and had no opportunities to do anything else, they always felt isolated. ²⁹

4.328 We have considered whether the discrepancy between the failures to remove spinal cord that were identified after the Meat Hygiene Service became responsible for inspection and the lack of reports of such failings before 1995 is attributable to a fall in the standard of performance by the inspectors when the Service took over. This does not accord with the evidence which we have just rehearsed. We believe that with the levels of staffing that existed, and the variations in standards that prevailed, meat inspectors were not ensuring that all spinal cord was removed from carcasses which were stamped. Why were these shortcomings not identified by the monitoring visits that were made by the vets who were reporting to Mr Hutchins and then to Mr Simmons?

4.329 We have concluded that the answer to this question is that these vets were not carrying out a thorough check on the removal of spinal cord. They were required to check on a wide range of statutory obligations in the slaughterhouse. While there was general concern as to the implication of the SBO Regulations in the gut room, no such concern was expressed in relation to standards of removal of the spinal cord. The evidence suggests that monitoring by the vets concentrated on the former and on meat hygiene regulations.

4.330 The veterinarians who served in the Meat Hygiene Division at Tolworth were agreed that the SVS Field Service were not involved in overseeing the means by which the SBO was removed from the carcasses. Mr Peter Hewson so stated in relation to the period between January 1990 and April 1991 when he was a DVO at Barton Hall Animal Health Office. ³⁰ He told us:

The accent was really on . . . the material being collected, being disposed of hygienically and safely; not was it being removed from the carcass hygienically and safely? ³¹

4.331 Mr Soul agreed:

. . . at this time there was a great deal of concern about hygiene standards in British slaughterhouses. The whole focus of the visits by the veterinary officers and the RMHAs at that time was looking at fresh meat hygiene in compliance with the fresh meat hygiene regulations, rather than with the SBO controls . . . it is a question of the emphasis - the prioritisation that was put on those different areas of work. ³²

4.332 Mr Baker agreed in oral evidence that those at Tolworth perceived the VOs' role as making sure that the SBOs were disposed of properly rather than examining how they were extracted. ³³

4.333 Mr Crawford told us that:

. . . they were asked to ensure that SBOs were being handled as they were required, kept separate, identified as such. But the emphasis would have been on hygienic production of meat at that time, rather than separation of the SBO from the carcass. ³⁴

4.334 Mr David Taylor added that the important thing was that anything that was being removed as being unfit should not get back into the human food chain. Therefore it was vital that it was properly stained and properly handled and certificated from one place to the other. ³⁵

4.335 This evidence completes the material that had led us to conclude that the failings in relation to the removal of spinal cord that were identified in 1995 exemplified a situation that had prevailed from the time that the human SBO ban was introduced.

4.336 We have set out this evidence in detail because the picture that it paints is clear and significant. The operation of sawing the carcass in half down the spinal cord would sometimes be carried out in a manner that left the spinal cord intact and fully exposed so that it could be totally removed. Sometimes it would result in the spinal cord being cut into segments or shredded. Sometimes a deviation of the saw would leave sections of vertebra uncut, with spinal cord trapped inside. Slivers of spinal cord could remain concealed behind the meninges which lined the spinal column.

4.337 With hindsight, we do not think it was reasonable, under the existing structure, to expect that where the slaughterman did not succeed in removing all the spinal column the meat inspector would ensure that this was done before the health stamp was applied. Just as standards of operation and hygiene varied from slaughterhouse to slaughterhouse, so did standards of meat inspection. The degree of coverage provided by the meat inspectors depended upon the decisions of the individual local authorities which employed them as to the staff that they needed to retain to perform their duties.

4.338 In the large slaughterhouse the meat inspector formed part of a conveyor belt system. The smaller slaughterhouses received a visit from an inspector to inspect the kill at the end of the day. In the larger slaughterhouses the pressures on the meat inspector could be intense. It would not have been realistic to expect that inspectors subject to such pressures would identify each occasion on which a piece of spinal cord remained in the spinal column and hold up the process by refusing to apply the meat stamp until it was removed.

4.339 In 1995, when meat inspectors came under the single employment of the Meat Hygiene Service, it proved possible to improve standards and change techniques until a stage was reached where the spinal cord was regularly removed in its entirety. This was achieved, however, only by giving this matter focused and continuous attention, and by augmenting the number of meat inspectors employed by the Service. The standards ultimately achieved afford no guide as to what it was reasonable to expect in 1990.

The course of events in 1990

4.340 The decision to refer slaughterhouse practices to SEAC was announced by Mr Gummer to the House on 21 May 1990. It followed expressions of concern about MRM from a number of quarters, including Mr Meldrum himself. Mr F Taylor of Meat Hygiene Division was asked to produce a paper for SEAC. He did so on the basis of 'widespread consultation on technical aspects'. ³⁶

4.341 The results of that consultation confirmed the comments that had been made, in and after the consultation process, that it was not possible to ensure that a carcass was split without damage to the spinal cord and contamination of the spinal column.

4.342 The revised draft of Mr Taylor's paper included a description of the manner in which damage to the spinal cord would, in some instances, inevitably lead to contamination of the vertebrae with central nervous system tissue. This passage survived virtually unchanged to the final version of the paper.

4.343 The revised draft followed the form of a typical submission to Ministers, setting out three policy options, commenting on each, and recommending one. The option recommended was the exclusion of the vertebrae from the production of MRM. If SEAC was to be asked to advise on the action that should be taken we think that it was helpful that it should be informed of the options considered by MAFF and of the reasons why MAFF preferred one of them. ³⁷

4.344 The revised draft was circulated for comment. In response to it, Mr Meldrum indicated dissatisfaction with the recommendation of the preferred option. He did not believe that there should be any recommendation 'at this stage'. It seems to us that Mr Meldrum was not personally persuaded that this option was the right one. In suggesting that the paper should emphasise that 'MRM was being obtained from totally healthy cattle in which the agent would either be totally absent from the brain or spinal cord or present in very low quantities indeed' he sought to slant the paper in favour of the option of 'giving clear advice to the industry and to local authorities as to how to reduce any possible contamination of MRM'. He suggested that this option should be presented 'in a rather more positive fashion'.

4.345 If SEAC's advice on the policy option was likely to be treated as decisive, as we believe it was, we can see no objection to discussion within MAFF as to how the relative merits of the options should be presented. In the event, the options were removed from the paper before it went to SEAC. The reasons are discussed below. We comment here with hindsight that while it would have been helpful to have a description of the options and MAFF's perception of their merits, it would have been inappropriate for SEAC to be asked to select the appropriate option. The preferable course would have been for MAFF officials themselves to have recommended the preferred policy option in the light of advice from SEAC on those aspects of the matter that fell within SEAC's expertise. While SEAC could have been involved in debate on the options, the ultimate decision should have been reserved for MAFF.

4.346 With the help of Mr Bremner, Mr Taylor had refined his paper by the end of August to incorporate comments received. Mr Lawrence was expected to submit it in Mr Lowson's absence on leave. ³⁸ It included a list of 'possible courses of action' - the original options - and 'conclusions'. These recommended further research to evaluate the risk of contamination and, if such a risk were established, leant in favour of the option of banning the extraction of MRM from the vertebrae.

4.347 Mr Meldrum remained unhappy with the paper. He did not wish SEAC to be encouraged to recommend action that went beyond what had been proposed within the SVS as 'presentationally it will appear as if our advice is faulty'. He asked that the paper should include 'advice we have given so far to the industry on MRM production and, in particular, to Local Authorities on removal of spinal cord tissue'. ³⁹

4.348 It may be that attempting to comply with this request led to delay, for we do not believe that any advice had been given to the industry or to local authorities. It may be that delay occurred because Mr Cockbill, Head of Food Standards Division, intervened. Mr Cockbill had different reservations about the option that involved legislating to ban the extraction of MRM from bovine vertebrae. He was concerned about European law and enforcement problems. While he did not suggest that the option of such legislation 'should necessarily be excluded from the consideration' of SEAC, he wanted the paper to be redrafted to give more emphasis to the option of 'the rules and guidance and controls on ensuring that the spinal cord material is properly removed from the carcass at the slaughtering stage'. ⁴⁰

4.349 At all events, October found Mr Lowson in the course of preparing a paper for SEAC on slaughterhouse practices, which incorporated Mr Taylor's draft material. The final draft incorporated some points raised on 11 October by Mr Bradley, who had found the draft 'superficial'. ⁴¹

4.350 In the final paper, Mr Lowson summarised a number of possible areas of research and development, most of which were designed to enable a better appreciation to be made of the extent of the risk of contamination carried by the carcass-splitting operation. He removed from the paper, however, the list of policy options. The paper simply concluded by inviting SEAC to advise:

Whether any action or guidance is required in relation to slaughterhouse practices, and whether any new R&D is needed, and if so with what priority. ⁴²

4.351 We do not consider that Mr Lowson can be criticised for removing from the paper the specific options and conclusions, particularly having regard to the apparent difference of view between the authors and Mr Meldrum as to the preferred option. At the same time we think that it was unfortunate that SEAC was unaware of the options that MAFF officials had been debating.

4.352 Before the meeting at which at which they were to discuss slaughterhouse practices, members of SEAC made slaughterhouse visits in order to see some of the practices at first hand. This was sensible and commendable. It was not, however, calculated to give SEAC an accurate impression of what happened on the ground. As Mr Lowson, who accompanied one group, put it:

Nobody would have supposed that people would work normally with a group of government inspectors standing beside them watching what they were doing, and nobody was under any illusion that that was what was happening. My impression of this being a high quality abattoir - that was certainly borne out . . . Nobody was suggesting that this was what you would expect to see in an abattoir on any day of the week. ⁴³

4.353 Dr Tyrrell explained to us that the purpose of the visit was 'to look at the thing on the basis of broad principles and get a bit of a feel of it by going to one or two particular abattoirs . . . there was no way we could have seen it all in one abattoir'. ⁴⁴

4.354 Oral evidence given to us confirmed the statement in the minutes of the sixth meeting of SEAC that some of the members who had been involved in the slaughterhouse visit had noted that if proper procedures were followed specified offals could be satisfactorily removed at the slaughterhouse and, in particular, that the spinal cord could be extracted from the carcass without difficulty. ⁴⁵ Dr Tyrrell told us that:

We were shown that you could in fact remove a spinal cord without leaving anything that looked remotely like a bit of nervous system behind. ⁴⁶

4.355 Mr Lowson said:

They did watch the removal of the spinal cord and I think some members of the Committee were actually quite surprised how cleanly the spinal cord could in fact be removed. ⁴⁷

4.356 Professor Barlow was not in the group that saw spinal cord removed cleanly and easily. In a statement he told us this about his visit to a slaughterhouse:

I was particularly concerned over the preparation of the sides of beef. The sagittal cut with a reciprocating saw was bound to smear spinal cord tissues along the kerf and also the saw blade, which was unlikely to be completely removed by subsequent hosing of the sides and blade.

Of even greater concern to me was the way in which the remnants of spinal cord were removed from each half of the vertebral canal; the operative wore a chain-mail glove and drew his forefinger down each side raking nervous tissue onto the floor to be hosed away subsequently. Any spicules of bone preventing access by his finger were chipped away with a cleaver. Even carefully done, it is inevitable that occasional bits of meninges or dorsal root ganglia would remain from time to time.

However, I confess that at the time I was more concerned for the operative than the ultimate consumer of the beef. ⁴⁸

4.357 Mr Pepper did not go on a slaughterhouse visit with other members of SEAC, but had this to say of his experience on other visits to slaughterhouses:

The things that I could contribute at that time to SEAC were: is it possible to remove the spinal cord from where it lies? My answer is: it is not only possible, I have seen it done on many, many, many occasions, so I know it is possible. In terms of making the link between the science: is spinal cord infected, is it likely to be infected; and policy: let us remove all spinal cords, it seems to me the link is what SEAC is being asked for in that situation. One person at least on that committee was able to say, 'I know it is possible because I have seen it done'. ⁴⁹

4.358 We asked Mr Pepper whether he would have found it surprising if in four cases out of 1,000 a proportion of spinal cord was not removed. ⁵⁰ He replied that he would not have been surprised if there had been a level of failure to comply with the law, though he would not put a figure on it. His reaction to a suggestion of 100 per cent compliance would have been 'Where were you born?' ⁵¹

4.359 Papers for the sixth meeting of SEAC, which was to be held on 1 November, were sent out on 23 October. ⁵²

4.360 The paper on slaughterhouse practices was one of a number of detailed papers supplied to SEAC for consideration at this meeting. Topics included:

1. The rendering industry and the production of tallow
2. A deactivation protocol
3. Bioassay of experimental samples in mice
4. Epidemiology, with particular reference to the apparent incubation period
5. Risk assessment research
6. Possible changes in the scrapie agent.

4.361 The agenda also included the following matters arising from the previous meeting:

1. Research coordination
2. Surveillance of spongiform encephalopathies in pigs, hounds and cats
3. A paper by the National Farmers Union (NFU)
4. Transmission experiments. ⁵³

4.362 We did not seek to explore the discussion that took place at SEAC's sixth meeting until Phase 2 of the Inquiry. This meant that we only heard oral evidence about this from three of those who were present, Dr Tyrrell, Mr Lowson and Mr Pepper.

4.363 The preparation of the paper on slaughterhouse practices had taken MAFF officials over four months. It had involved wide consultation and investigation of the practical effects of the practices under discussion. It raised a number of questions, most prominently the significance of the contamination with central nervous system tissue that occurred when the spinal cord was damaged in the course of carcass-splitting. That contamination was primarily of the spinal column, which had obvious implications in relation to the use of the spinal column as a source of MRM.

4.364 Quite apart from this contamination, the paper raised the question of the infectivity of peripheral nervous tissue in way of the spinal column. This had been troubling Mr Meldrum, who was perhaps stimulated by learning of concerns about dorsal root ganglia expressed by Mr Godfrey (see paragraph 4.248).

4.365 The paper indicated a number of areas in which R&D could be useful, including bioassay of potentially contaminated tissue.

4.366 The paper also raised a number of questions about the contamination risks involved in the practice of pithing. A further question not expressly raised, but of concern to Mr Bradley, who attended SEAC's meeting as an observer, was the possibility that pithing might result in infected nervous tissue being carried round the vascular system before the heart stopped beating. ⁵⁴

4.367 SEAC's response to this paper is reported in the following paragraph in the minutes:

Those members who had been involved in the slaughterhouse visit had noted that, if proper procedures were followed, specified offals could be satisfactorily removed at the slaughterhouse, and in particular that the spinal cord could be extracted from the carcass without difficulty. The Committee therefore concluded that, provided all the rules were properly followed and supervised, there was no need to recommend further measure on the grounds of consumer protection (operator safety was a matter for HSE). ⁵⁵

4.368 The minutes suggest that the reasoning of the Committee was as follows:

If all the rules are properly followed and supervised, spinal cord will be extracted without contamination. Provided that this occurs there is no need to recommend further measures.

4.369 In his evidence Dr Tyrrell also suggested that SEAC's advice was subject to the proviso that the spinal cord was entirely removed:

We were shown that you could in fact remove a spinal cord without leaving anything that looked remotely like a bit of nervous system behind. But we then made a conditional view, gave a conditional view, which was provided that was what happened, we regarded it as acceptable. ⁵⁶

4.370 Neither Dr Tyrrell, Mr Pepper nor Mr Lowson could recollect discussion about MRM and none was minuted. We asked what consideration SEAC gave to MRM at the meeting and Dr Tyrrell replied: 'I do not think it was much, anyhow. Perhaps that is why it is not mentioned in the minutes'. He suggested:

I suspect that what happened was that we reckoned that there was not really a problem with MRM if the vertebral column was being cleanly cut and dissected. So the MRM was really, in a sense, covered by our comment that if the regulations were satisfactorily carried out, and they were properly monitored, then there was not a problem. ⁵⁷

4.371 So far as concerned the areas of research that the paper suggested could be useful in quantification of the amount of central nervous system tissue that might be getting into MRM, Dr Tyrrell informed us in a statement:

The conclusion of SEAC, at the meeting, did not cover research and development or its priority. ⁵⁸

4.372 In his oral evidence Dr Tyrrell said:

But we stopped there and, as I recall it, we never really came clean on any of these alternatives here. ⁵⁹

4.373 Mr Pepper told us:

I do not think we did give the answers that were expected of us as it happens. ⁶⁰

4.374 If the minutes, and Dr Tyrrell's evidence, are correct, SEAC failed to deal with the questions raised by the paper on slaughterhouses. The paper described contamination that inevitably occurred as a consequence of carcass-splitting and asked for advice in respect of this. It was of no assistance to reply that no action was necessary provided no contamination occurred.

4.375 We do not believe that the members of SEAC intended to give an answer as unhelpful as this. We feel that some, at least, must have advised on the basis that a degree of contamination would inevitably occur on occasion and that this was acceptable. We believe, however, that those who were not familiar with slaughterhouse practices were deceived by the apparent ease of the operation that they witnessed. This led them to conclude that if slaughterhouse procedures were properly followed and supervised the type of contamination described in MAFF's paper would occur so rarely that it could be disregarded.

4.376 In reaching this conclusion, there was much of which members of SEAC were unaware.

4.377 They were unaware both of the extent to which there was cause for concern about contamination of MRM and of the actual concern that was felt. Dr Tyrrell told us that he was unaware of anxiety about standards in slaughterhouses and that, had he known of this, it would have been bound to colour the advice that they gave. ⁶¹ He was not aware of concerns expressed by Ministers or MAFF officials. ⁶² SEAC was not told of the concerns expressed in responses to the SBO consultation process, nor of concerns expressed by IEHO. It was not aware of the options that MAFF officials had been debating in the course of 1990.

4.378 If, as we believe, SEAC's advice was based upon its own assessment of the ease with which spinal cord could be removed, it was advising on a matter on which it was much less qualified than were MAFF officials to form a view.

4.379 We explored with SEAC the nature of the contribution that it was in a position to make to decisions about slaughterhouse practices:

Lord Phillips: We have asked ourselves, as a Committee: what really did SEAC have to contribute to this particular debate? I can see that there might have been a question, would this amount of contamination matter; there might have been a question, is pithing liable to give rise to a pulmonary embolism which could result in contamination from the brain in other parts of the cow; but on the question, are slaughtering practices going to result in one bit of tissue coming into contact with another, did SEAC have anything really to contribute?

Dr Tyrrell: Well, Sir, as I recall it we had already made a firm statement that it was a bad idea - I put it no higher than that - to allow central nervous system to spread around in the course of the slaughtering abattoir practice, and in one specific instance it was what about splitting heads of cattle before the meat was recovered, the cheek meat was recovered? We said no, it does not make sense at all, do not do it.

Lord Phillips: Can I just pause there? Is that something on which SEAC had anything particular to contribute, apart from common sense?

Dr Tyrrell: I think it had in the sense that we have already referred to the fact that there was some misunderstanding as to the very high potency of infectious material inside the brain, and if people were thinking, 'Oh, it is rather like the contamination you can see, if you wipe a duster over, you can see something on it', something that is totally invisible is quite enough to carry infection. So I think there was a point in getting it back to us; that infection is very high and therefore . . .

We were also asked to comment on it and we did say, 'We do not know much about this modern practice, but we will do what we can, but only after we have been to see an abattoir or abattoirs'. ⁶³

4.380 It seems to us that Dr Tyrrell correctly acknowledged that his Committee was not well equipped to advise MAFF on the physical consequences of slaughterhouse practices. What SEAC was well qualified to advise on was the extent to which those consequences would, or might, involve risk to man.

4.381 SEAC was particularly well placed to advise on the quantity of central nervous tissue that might suffice to infect. That was a matter that it had already considered in its advice to the CMO on the safety of beef. If SEAC held the view that something that was 'totally invisible' was quite enough to carry infection, that view would be a valuable contribution to the debate.

4.382 Our conclusion is that SEAC did not discuss the questions raised by MAFF's paper on which it was best qualified to advise. It did not advise on the significance that attached, or might attach, to the contamination that the paper described as inevitable. It did not advise on any further research that might assist in solving this problem. It did not give any indication of the amount of central nervous tissue that might contain an infective dose. All these questions it side-stepped on the basis that if the rules were properly observed and proper supervision was maintained, these problems would not arise.

4.383 The paper which so carefully described the operation of carcass splitting and the contamination that would inevitably result was prepared to inform SEAC of matters that fell outside its expertise. The expectation was that it would address these matters in its advice. In the event it advised instead on the basis of conclusions formed on a slaughterhouse visit to witness procedures with which it was not familiar in demonstration conditions that were far removed from ordinary slaughterhouse conditions.

4.384 Are the members of SEAC open to criticism for dealing with the paper on slaughterhouse practices in this way? We do not think so.

4.385 In the first place we feel that it would have been more helpful to SEAC if the advice sought from it had been more specifically targeted. We have already indicated that it would have helped if SEAC had been informed of the options that MAFF officials were contemplating. We believe that the appropriate way to use SEAC's expertise in relation to slaughterhouse practices and MRM would have been to seek advice on the significance of the contamination that was involved. SEAC could profitably have been involved in discussion about the possible options for avoiding or reducing contamination. It was not, however, an appropriate use of SEAC's expertise to expect it to weigh up all the matters set out in the paper presented to it and decide upon the appropriate policy option. That was something that MAFF officials were better placed to do.

4.386 In the second place we feel that it was asking a lot of SEAC to expect it to deal comprehensively with the slaughterhouse paper when it formed part of such a heavy agenda. In this context it is worth quoting a portion of a Progress Report sent by Mr Lowson to Mrs Attridge on 4 July:

The group has not yet been able to establish a crisp and businesslike way of working; the production of documents and advice is cumbersome and as a result inadequate attention has been paid to some issues. The Committee (and particularly the Chairman) obviously feel uncomfortable about offering firm advice on specific measures and from now on may well try to avoid doing so, preferring to describe the scientific situation and explicitly leaving the policy decisions to Ministers. It was only with some difficulty, for example, that they reached a clearer conclusion in writing on the issue of the removal of head meat than that contact between meat and brain or spinal cord should if possible be avoided. ⁶⁴

4.387 Had SEAC been aware of the extent of the concerns expressed about contamination resulting from carcass-splitting and its impact on MRM, and had it been aware of the provisional conclusions reached by MAFF officials, we think it likely that it would have endorsed the suggestion that further research be carried out in order to quantify the amount of spinal cord material getting into MRM. This might have led to SEAC endorsing the further option of recommending a ban on the extraction of MRM from the bovine vertebrae. We would not put it higher than this. In 1995 it was demonstrated that, in a small minority of cases, carcasses were being health stamped despite the fact that they contained portions of spinal cord. It was only after considerable debate that SEAC recommended that MRM should no longer be extracted from bovine vertebrae. We cannot be confident that the same decision would have been reached in 1990.

4.388 Witnesses described to us their understanding of SEAC's advice and, in particular, its proviso.

4.389 Mrs Jane Brown took over as head of Meat Hygiene Division in September 1990. She understood SEAC's advice to indicate that the 'inevitable' contamination referred to in the paper before them was acceptable ⁶⁵ provided that proper slaughterhouse practices and supervision ensured that this was kept to a minimum. ⁶⁶ In a written statement she remarked:

I considered that the proviso in SEAC's advice concerning the need to ensure that the rules were properly followed and supervised was an endorsement of the 1989 Regulations. The paper which SEAC considered had made it plain that in practice there was a risk that some contamination with fragments of spinal cord or nervous tissue could occur. I believed that if SEAC considered that these risks (which related both to MRM and to slaughterhouse practices affecting the production of carcass meat) were unacceptable, they would have phrased this conclusion in stronger terms, stressing the need to ensure 100% avoidance of this type of contamination. ⁶⁷

4.390 Mrs Attridge also said that she understood SEAC's advice to be subject to the proviso 'that the slaughterhouse processes, the practices in slaughterhouses' were carried out correctly. ⁶⁸ She appreciated that 100 per cent removal of the spinal cord could not be guaranteed, for she had seen a draft of the paper on slaughterhouse practices. She did not read the proviso as incompatible with the paper.

4.391 Mr Meldrum's position is summarised in the following paragraph of a statement made to the Inquiry:

. . . my concerns at the time related to risks related to the use in food for human consumption of MRM derived from bovine carcasses as a result of fragments of spinal cord inadvertently remaining in the spinal canal and contamination from carcass splitting. All the background information available at the time which was pertinent to an assessment of these risks and which had been put together as a result of extensive consultation within MAFF had been provided to SEAC in SEAC 6/1, the paper on slaughterhouse practices (see paragraph 16 above). SEAC had been asked to consider 'on the basis of the available evidence whether any action or guidance is required in relation to slaughterhouse practices, and whether any new R&D was needed, and if so, with what priority'. Having received the information in SEAC 6/1, coupled with the visit of several members of SEAC to slaughterhouses, the Committee had concluded that there was no need to recommend further measures on the grounds of consumer protection. This allayed my concerns to the extent that it indicated that SEAC were not unduly worried about any risks raised in SEAC 6/1, in particular those risks arising from the fact that 'inevitably when bovine carcasses are split through the centre of the vertebral column in the slaughterhouse some nervous tissue can remain and some contamination of the vertebrae with central nervous system (CNS) tissue can occur'. ⁶⁹ SEAC made the important caveat that they were content provided that all the rules were properly followed and supervised. I had no reason to believe that this was not the case . . . ⁷⁰

4.392 Initially we were concerned by the fact that the evidence of each of these witnesses was hard to reconcile with the meaning of SEAC's proviso as it appeared in the minutes, a draft of which had been sent to each by Mr Lowson on 8 November. Mrs Attridge had no recollection of receiving these ⁷¹ and we have concluded that it would not be right to proceed on the assumption that any individual witness read these draft minutes. Mr Lowson's minute to Mr David Maclean, dealing exclusively with slaughterhouse practices, was sent out a day later. This did not make it clear that SEAC was advising on the basis that, if proper procedures were followed, the spinal cord could be extracted from the carcass without difficulty.

4.393 Anyone reading the minute to Mr Maclean and who was aware of the references to inevitable contamination in the paper that had gone to SEAC could reasonably conclude that SEAC's view was that, provided such contamination was kept to a minimum by proper slaughterhouse practices and due supervision, such contamination was not cause for concern.

4.394 What of Mr Lowson himself? In oral evidence he told us:

My conclusion was that they shared the view that total avoidance of contamination was not necessary. But that is not written down in so many words in the minutes of the SEAC meeting or of the advice which they offered. ⁷²

4.395 We have already expressed our own belief that some, at least, of the members of SEAC must have advised on the basis that slaughterhouse practices would, on occasion, involve a degree of contamination with spinal cord (see paragraph 4.375). Precisely what was said, and by whom, at SEAC's meeting on 1 November cannot now be recalled. We have no reason to think that Mr Lowson's understanding of SEAC's view was not one that it was reasonable for him to reach.

4.396 We have seen that Mrs Attridge, Mrs Brown, Mr Lowson and Mr Meldrum all understood that SEAC's advice that no action was necessary in relation to slaughterhouse practices was subject to the proviso that slaughterhouse procedures were properly followed and supervised.

4.397 We explored with witnesses whether that proviso should not have acted as a 'wake-up call' - the phrase was Mr Capstick's - that MAFF needed to take steps to ensure that the proviso was satisfied. We suggested that this was particularly necessary because hygiene standards in general in slaughterhouses were known to be poor and there could therefore be no confidence that removal of spinal cord would be properly effected and supervised.

4.398 We have set out in some detail evidence of the poor standards of hygiene prevalent in so many slaughterhouses. Officials at MAFF were well aware of the position. Mr Cruickshank told us that in 1989 there was a feeling within the Ministry:

That the standards of hygiene in slaughterhouses was pretty low in the UK - a good deal lower than in most other developed countries. ⁷³

4.399 Mr Crawford told us that he agreed with this evidence. He told us:

It was well recognised that the standards were poor. The export approved . . . was of a higher standard than the domestic slaughterhouse. But many of the domestic slaughterhouses had major problems. These were well known. ⁷⁴

4.400 Mr Crawford went on to suggest that poor hygiene standards had no read-across to the standards of enforcement of regulations, such as the SBO Regulations, designed to protect human health. MAFF had had no cause for complaint in relation to the handling of that aspect of practice in slaughterhouses. ⁷⁵

4.401 The response of other witnesses was to similar effect. It did not follow from the fact that hygiene standards were poor that meat inspectors were disregarding their obligations in relation to unfit meat. They believed that the SBO Regulations were being properly supervised and that adequate instructions had been given to local authorities in respect of the importance of compliance with these Regulations.

4.402 Mr Capstick expressed the view that SEAC, by its proviso, 'ducked the question' of whether the process of removing the spinal cord was in fact being done effectively. He was unaware of whether that proviso was transmitted, as a 'wake-up call', to the meat inspectors and local authorities. This was not his personal concern. He suggested that DH and MAFF shared responsibility. So far as MAFF were concerned, he thought that Mr Lowson, as Secretary of SEAC and head of Animal Health Division, and Mrs Brown as head of Meat Hygiene Division might have a role; also that Mr Keith Baker and his team should have been checking that sides of beef were clean of spinal cord. ⁷⁶

4.403 Mr Lowson told us that he had no personal responsibility for seeing that SEAC's proviso was satisfied as his Division was concerned with animal health, not human health. His duty was to see that SEAC's advice was relayed to those within government with relevant responsibilities. Mr Lowson circulated the draft minutes of the SEAC meeting under cover of a minute which stated that, so far as slaughterhouse practices were concerned, SEAC's advice required 'no further action' (see paragraph 4.293). That was true only if SEAC's proviso was satisfied.

4.404 Mr Lowson has stated that:

At the time I had no grounds for believing that local authority enforcement was such that industry could not be relied upon to comply rigorously with SBO Regulations; and I was aware that State Veterinary Service colleagues were active in monitoring the situation. ⁷⁷

4.405 This was explored further when Mr Lowson returned to give evidence in Phase 2. He was asked whether he did not consider that SEAC's proviso required him to convey the message that positive measures needed to be taken to make sure that spinal cord was removed.

No, I believe those responsible were already aware. If you look at the measures that were being carried forward in the context of the time, there is a good deal of evidence of that. This is not intended as a complete list of all the action that might have been taken. For example, the Chief Veterinary Officer asked Mr Baker to check on the enforcement of the regulations in February 1990, that is YB90/02.06/6.1. In June of 1990, YB90/6.21/18.1, there had been a telex sent out from Tolworth calling for checks on slaughterhouse practices that had been sparked off by concerns relating specifically to mechanically recovered meat.

At the time that the SEAC slaughterhouse visit took place, we were of course setting in hand the measure to remove specified offals from the animal feed chain which was implemented in September of that year, and that was associated with further instructions from headquarters (Mr Baker and Mr Crawford), to the Veterinary Service to ensure that specified offal measures were being correctly enforced, and a letter from my Division to Local Authorities, again drawing their attention to the need to enforce the regulations.

Although these were in the context of the animal feed regulation, the part of the process which happened in the slaughterhouse was the same, and the measures that had to be enforced in the slaughterhouse were not changed as a result of the introduction of the feed ban. So instructions to the field and requests to local authority enforcement agencies to check on the enforcement of the SBO ban in the context of introducing a feed measure were equally relevant to the enforcement of the SBO ban that it was already in existence. So I was satisfied in brief that those responsible for enforcement did not need to be reminded of the importance of adequate enforcement implied by the SEAC advice. ⁷⁸

4.406 Mrs Brown explained why she was confident about standards of local authority enforcement.

I think it is important to draw a distinction between the enforcement and supervision of the hygiene standards in slaughterhouses and the enforcement and supervision of the SBO controls, because as you have received a lot of evidence on problems relating to hygiene and inspection and veterinary supervision in slaughterhouses, I think it is fair to say that we did not have similar concerns about the way in which local authorities approached the enforcement of the SBO regulations.

I think the discussions that we had had, that my colleagues had had in the early part of 1990 with the Local Authority Associations, indicated quite clearly that the local authorities regarded these regulations as a very important part of the mechanism to protect human health; and the reason that there were these obviously at times quite difficult discussions with the Institute of Environmental Health and so on were because they were concerned about the practicalities of enforcement, and were keen to see that the protection worked properly. ⁷⁹

4.407 She explained that meat inspection was a more precise duty than hygiene enforcement, 'which was a much more complicated sort of requirement'. ⁸⁰ When asked how, if hygiene was lamentable, one could be sure that meat inspection was perfect, she replied:

I think because our surveillance was carried out by the meat trained VOs in the field . . . The same person was going into a slaughterhouse to check on all aspects of the operation of that slaughterhouse. ⁸¹

4.408 Mrs Brown also referred to a telex from Mr Baker to DVOs on 12 November which asked for details of how slaughterhouses were handling SBO. ⁸² Mrs Brown told us that she thought that this related both to enforcement of the animal SBO ban and to slaughterhouse practices considered by SEAC.

I mean there were two things going on simultaneously. There was the introduction of the animal SBO ban which was pretty recent, that was September 1990, and there was the SEAC consideration of slaughterhouse practices. Now, I was aware that this telex went out from Keith Baker ten days or so after the SEAC meeting; and I think my impression was that this was addressing both areas of concern. That there was the need to check on the way things were being handled through the animal feed chain, and also to keep up the level of vigilance which, as I say, was already pretty high because of the reminders that had been issued previously on how the slaughterhouses were dealing with the whole of the SBO exercise. ⁸³

4.409 Mrs Attridge told us that she was very well aware of the fact that general standards in UK slaughterhouses were variable, as would have been most people dealing in the animal health hygiene area. ⁸⁴ She referred to difficulties in tackling concerns about these, particularly in non-export slaughterhouses, where the VFS had no powers of entry and had to 'tag along' with the local authority inspector. ⁸⁵

4.410 Dealing with SEAC's proviso, Mrs Attridge said that there were arrangements to check on the position at slaughterhouses and the reports indicated that problems were being dealt with as and when they arose. When it was pointed out that these reports were not initiated until 1991 she said that 'prior to that there had been a more informal report back'. She said that she had every confidence that the veterinary staff would ensure that the Regulations were met. ⁸⁶

4.411 Mr Meldrum had, in September 1990, been under the impression that some advice had been given to industry on MRM production and to local authorities on removal of spinal cord tissue. He had asked for particulars of this to be inserted in the SEAC paper. No particulars were inserted.

4.412 Mr Meldrum was asked whether any advice had been given to local authorities about removal of spinal cord and tissue. He answered:

I am having difficulty in finding what I wanted to find. I have been searching and searching and searching because at that time when I made that comment I assumed that to be the case. And nobody came back to me and said 'that is not the case'. I am certain that there was a great deal of discussion between Veterinary Officers who were working, doing audits in slaughterhouses between themselves, and EHOs and meat inspectors at the time they did their routine inspections both of export approved and domestic premises. I am certain that was an ongoing discussion. I have failed to find any specific instructions of the nature that I had been driving at in the papers that I have reviewed so far. ⁸⁷

4.413 We have set out above (at paragraphs 4.147-4.148) the telex that was sent by Mr Bremner on 21 June 1990 to all RMHAs. That gave the general instruction that VOs should ensure full compliance with the 1989 SBO Regulations on their visits to slaughterhouses and cutting rooms and that these Regulations should be added to the list to be checked on Form MH1.

4.414 Mr Baker's telex of 12 November, to which Mrs Brown referred, was dealing with the handling of SBO at renderers and at slaughterhouses and would not focus the attention of the recipient on the need to ensure full removal of the spinal cord. Mr Baker told us that he had no involvement in the reference of slaughterhouse practices to SEAC, did not receive the minutes of their meeting and, indeed, was unaware that SEAC had considered MRM. ⁸⁸

4.415 That telex, and the subsequent instructions that were sent in relation to monitoring of the 1989 Regulations, were all sent in an attempt to ensure that SBO was not getting into animal feed. No instructions or guidance was sent to emphasise the importance of monitoring full removal of the spinal cord.

4.416 We were initially sceptical about the proposition that there was no read-across from the standard of hygiene in slaughterhouses to the standard of compliance with regulations relating to unfit meat. We were, however, persuaded that it was not right to infer that slaughterhouse operatives and meat inspectors in a slaughterhouse with poor hygiene would be less rigorous in ensuring that offal which was unfit for human consumption, including SBO, was properly removed from the carcass.

4.417 We note that, while shortcomings were discovered in 1995 in relation to the removal of spinal cord, the extent of these was relatively modest and in no way reflected the shortcomings that had been identified in relation to general hygiene and activities in the gut room.

4.418 We do not consider that SEAC's proviso was intended to be a 'wake-up call' drawing attention to the need to take additional action in relation to performance by slaughterhouses and local authorities of their obligations under the Regulations, nor that MAFF officials should have interpreted the proviso in that way. Consequently, we do not criticise any individual in relation to the approach taken by MAFF towards MRM in 1990.

4.419 Mr Gummer had been reassured by his officials that there was no cause for concern about MRM. There was, however, public concern about slaughterhouse practices in general and MRM in particular, which was reflected in Parliamentary attacks on the Government's handling of BSE.

4.420 In these circumstances Mr Gummer decided to refer slaughterhouse practices to SEAC. SEAC did not have expertise in the technical aspects of slaughterhouse practices, but was well qualified to express a view on the significance of any contamination that resulted from them.

4.421 The reference of slaughterhouse practices to SEAC stimulated MAFF to carry out a detailed assessment of the contamination consequent upon carcass-splitting for incorporation into a comprehensive paper on slaughterhouse practices for SEAC. Contributions were made from various divisions, including the SVS, Meat Hygiene Division, Food Standards Division and Food Sciences Division.

4.422 This assessment noted that contamination would result from small pieces of spinal cord inadvertently remaining in the vertebral column. It also explained that carcass-splitting would inevitably, on occasion, transfer tissue from the spinal cord onto the carcass, where it would be concentrated around the cut surface of the spinal column. How much of this would remain after routine washing and be transferred into MRM recovered from the spinal column was unknown.

4.423 Those who carried out this assessment identified a number of options to address this contamination problem. The least was the giving of advice on carcass-splitting to the slaughterhouse operators and on inspection to local authorities. The preferred option, if the amount of contamination entering MRM was unacceptable, was to ban recovery of MRM from bovine vertebrae. Further research was desirable to quantify the contamination.

4.424 At this point most of the task necessary for assessment of the risk had been done. Input from SEAC was needed by way of confirmation that officials' proposed action was appropriate having regard to the contamination that MAFF officials had diagnosed as inevitable.

4.425 Had this question been put to SEAC we have little doubt that it would have endorsed the proposal for research to quantify the amount of spinal cord getting into MRM. In the event, having been asked to advise generally, SEAC advised on the basis of its own assessment that if slaughterhouse procedures were properly carried out there would not be a problem. This assessment was at odds with that of the authors of the paper, who were better qualified to make it.

4.426 SEAC's advice was treated as establishing definitively that the contamination described in the SEAC paper was not cause for concern. The effect of SEAC's advice was that no action of any kind was considered necessary, or taken, to address the potential risk posed by MRM until 1995. This demonstrates a serious breakdown in communication. SEAC's intervention had hindered rather than helped the process of risk evaluation and management.

4.427 This unhappy chapter in the BSE story demonstrates the importance of targeting advice sought from expert committees so as to ensure that they provide input based on their expertise. It also demonstrates the dangers of overloading a part-time committee of busy people.