Volume 6: Human Health, 1989-96
5. Human health developments: 1 January 1991 to 31 March 1995
Implementation of precautionary measures in relation to BSE
Introduction
Monitoring compliance with the SBO Regulations at slaughterhouses from 1 January 1991 to 31 March 1995

Introduction

5.150 In this section we shall look at the implementation of precautionary measures to protect human health against the possible risk of transmission of BSE between 1991 and March 1995. First, we examine the monitoring by MAFF of the SBO ban in slaughterhouses. Second, we examine the concerns raised about MRM during this period, noting that the Government did not introduce any precautionary measures on MRM until December 1995 (discussed in Chapter 6). Third, we look at the amendments made to the SBO Regulations during this period.

Monitoring compliance with the SBO Regulations at slaughterhouses from 1 January 1991 to 31 March 1995

5.151 Between January 1991 and March 1995, MAFF officials took a number of initiatives designed to ensure the effective monitoring of the SBO Regulations. These required the VFS to carry out both routine and additional visits to slaughterhouses. While Veterinary Officers (VOs) were expected in the course of such visits to maintain enforcement of all obligations imposed by the SBO Regulations, the emphasis was not on the removal of SBO from the carcass, it was on the disposal of the SBO once it had been removed from the carcass, ie, procedures in the gut room.

5.152 This reflected the fact that the motivation for their initiatives was a concern that SBOs should remain separated and distinguishable from other material destined to be rendered for animal feed. Officials were not motivated by doubts about the protection of human health. However, over the period covered by this chapter, they became increasingly anxious to ensure that the tissues covered by the human SBO ban were dealt with in a way which would not prejudice the animal feed SBO ban.

5.153 Mr Peter Hewson, between 1992 and 1995 a Superintending Meat Hygiene Adviser, explained in oral evidence:

The accent was really on was the material being collected, being disposed of hygienically and safely; not was it being removed from the carcase hygienically and safely? ¹

5.154 For this reason we have felt it appropriate to place our detailed review of the monitoring of the SBO Regulations in vol. 5: Animal Health, 1989-96. In this volume we shall concentrate on those aspects of the story which have specific reference to human health.

5.155 On 18 January 1991, the SVS circulated pro-forma report forms on compliance with the SBO Regulations for Divisional Veterinary Officers (DVOs) to complete. The pro-forma report sought little information in relation to the human food chain or SBO removal techniques, other than to ask whether, in those slaughterhouses where bovine brains were removed on site, there was a consequent risk of contamination of meat for human consumption. ²

5.156 The completion of the pro-forma reports by DVOs was continuous throughout 1991-95. However, SVS reports are missing for the following periods after the initial report in March 1991: April 1991, July 1991-February 1993, November 1993-June 1994, and November-December 1994. ³

5.157 So far as the removal of spinal cord from the carcass is concerned, we are aware of only one report prior to 31 March 1995 that identified a failure to ensure the full removal of spinal cord from the carcass. ⁴

Instructions issued by SVS Headquarters to SVS Field Staff on monitoring the SBO ban during 1991 to March 1995

5.158 During 1991 to March 1995, SVS Headquarters issued a series of instructions to SVS Field Staff to report on compliance with the SBO Regulations in slaughterhouses. As a result the frequency of SVS visits to slaughterhouses increased during this period, from occasional announced visits in 1991 to a requirement, introduced on 29 June 1994, for unannounced visits every two months. ⁵

Monitoring compliance with the SBO ban during 1991 and 1992

5.159 At the start of this period, bovine brain removal was under scrutiny by the SVS during their visits. Monitoring of brain removal was raised on 18 January 1991, when the SVS first circulated the pro-forma reports.

5.160 Mr Stephen Hutchins, SVO Meat Hygiene Veterinary Section, produced a summary of these reports from slaughterhouse visits in January and February, and forwarded it to Mr Iain Crawford, Director of the VFS, MAFF, on 5 April 1991. He noted that the method to remove brains from skulls varied, although it involved either removing the back or top of the skull, or splitting of the skull: ⁶

There was little or no evidence of meat intended for human consumption being exposed to risk of contamination by brain material. Head meat was generally removed prior to brain removal. Heads were opened in parts of the premises where no meat intended for human consumption was present. In the few cases where this was not the case, the undesirability of these practices was discussed with operators.

5.161 Mr Hutchins pointed out that in the few plants where contraventions had been reported the relevant local authority had been contacted to ensure compliance. He concluded that the overall picture appeared 'quite encouraging' with 'generally a high degree of compliance with the legislation'. ⁷

5.162 On 19 June 1991, Mr Hutchins minuted Mr Crawford summarising the results of the surveillance reports received for May/June 1991. He expressed concern about the contamination of meat for human consumption at six abattoirs where the brain was removed before head meat was harvested. The 'undesirability' of such practices had been discussed with local authorities. Mr Hutchins concluded that the overall picture remained quite encouraging and that the concerns over contamination of head meat should be resolved when amendments to the SBO Regulations in relation to bovine heads came into effect. The amendments were to be based on guidance previously issued by MAFF in June 1990. (See Chapter 4 and paragraph 5.205.) ⁸

5.163 The possible use of SBO-derived tallow in the human food chain had been discussed by SEAC on 7 March 1991 ⁹ (see vol. 11: Scientists after Southwood. It is also discussed in vol. 7: Medicines and Cosmetics). The issue was raised in a report prepared by Mr Hutchins on 7 May 1991, concerning the results of surveillance reports from rendering plants. The report noted the following on the use of tallow:

A wide variety of uses was reported, although specific details were not generally available. Options included, edible tallow . . . There was little evidence to suggest that tallow produced from SBOs was handled separately from tallow produced from other offals. ¹⁰

5.164 Mr Crawford referred to Mr Hutchins's minute on 8 May 1991, and noted in a minute to Mr Baker and copied to Mr Hutchins and Mr Lawrence:

As you know, tallow produced from the specified offals can be used for inclusion in animal feed (although our information is that it is not being put to that use) but not for human consumption. ¹¹

5.165 Mr Hutchins then wrote to the DVOs who had submitted reports indicating that SBO-derived tallow was being mixed with other tallow, to request further details as to the use of tallow. ¹²

5.166 We have not seen the response received by Mr Hutchins. However, in his written statement to the Inquiry he said that only one DVO had claimed tallow was used in the human food chain and, when the DVO was further questioned, he reported the claim to have been 'an error in the completion' of his report. ¹³ In a further minute to Mr Crawford on 3 June 1991, Mr Hutchins advised:

Further inquiries regarding these reports have now been completed. It is now stated that no SBO-derived tallow is used in the preparation of human foodstuffs (apparently an error in the original report). ¹⁴

5.167 However, the use of SBO-derived tallow was raised again on 30 July 1991, in a minute from Mr Crawford to Mr Lawrence discussing a conversation with Mr Ron Martin (CVO of Department of Agriculture for Northern Ireland (DANI) from March 1990 to March 1996). ¹⁵ Mr Martin had suggested that SBO-derived tallow from Northern Ireland sent to brokers in Great Britain could be upgraded and perhaps used for human and animal consumption. A minute from Mr Hutchins to Mr Crawford on 2 August 1991 recorded that some rendering plants sold their SBO-derived tallow to brokers, with no indication available as to its use. ¹⁶

5.168 We have found no further evidence of concerns over the use of SBO-derived tallow in the human food chain in this period. Later reports on surveillance returns note that there was no indication of the use of SBO-derived tallow for human consumption; however, it was not often possible to establish the 'ultimate destination' of the tallow. ¹⁷

5.169 We have found no further evidence in SVS surveillance reports during the rest of 1991 of any concern arising over the removal of SBO material or any further breaches of the SBO Regulations with implications for the human food chain.

5.170 No reports are available on the SVS surveillance visits to slaughterhouses during 1992. However, hygiene issues affecting slaughterhouses continued to cause concern within MAFF, as discussed earlier in this chapter.

Monitoring compliance with the SBO ban during 1993 and 1994

5.171 Surveillance reports prepared in 1993 again said that the removal of SBO material appeared satisfactory. There were some reports of minor infringements, such as failing to stain or separate SBO after removal; however, it was noted that, once these were reported, local authorities took remedial action. ¹⁸ MAFF remained aware of the problems of hygiene in slaughterhouses, as discussed earlier in this chapter.

5.172 In February 1994, Mr Crawford noted that some staff had been giving advance warning of their visits. 'Obviously this allows the operator to ensure that, at the time of the visit, everything is being done that should be done'. He gave instructions that all plants processing SBO be subject to unannounced visits by SVS staff during February and detailed reports compiled. ¹⁹

5.173 On 25 March 1994, Mr Alick Simmons noted in a summary of reports from slaughterhouses that, in general, compliance with the SBO Regulations was satisfactory. The removal of SBO from carcasses was 'correct'. He referred to Mr Crawford's request that visits be 'unannounced'. However, the summary noted that visits were 'made by appointment'. ²⁰

5.174 During the remainder of 1994, reports from the SVS did not highlight any problems in relation to the possibility of SBO entering the human food chain through lack of compliance with the SBO Regulations. ²¹ Mr Haddon commented in oral evidence on SBO removal in 1994:

. . . In April 1994 discussion was well under way on problems in the application of the SBO controls and the need to take further steps to make them easier to try to enforce and monitor. That was all at that point seen in the context of the handling of SBOs after they had been removed from the carcass, and a lot of work went on about that, and there was subsequent legislation, but none of that consideration included any sort of implication or suggestion that SBOs were not being properly removed from the carcass. ²²

Monitoring compliance with the SBO ban in January-February 1995

5.175 On 2 March 1995, Mr Simmons sent Mr Crawford and others in MAFF the summary report on SVS surveillance visits covering January and February 1995. Mr Simmons reported that:

Of the 348 slaughterhouses visited in the two month period, deficiencies in the disposal of SBO were reported in 10. These related to the absence of movement permits, inadequate staining and poor separation. In each case, the reports either indicate prompt resolution or that the problem has been taken up with the LA [local authority]. ²³

5.176 The summary report made no specific comments on the effectiveness of SBO removal from carcasses at slaughterhouses.

Overview on the monitoring of the SBO ban from January 1991to 31 March 1995

5.177 Mrs Jane Brown discussed the monitoring of compliance with the SBO Regulations during 1991-94, in her written statement to the Inquiry:

Meat Hygiene Veterinary Service's monitoring reports were the primary source of information . . . these reports did not suggest that there was any serious problem with the operation of the Bovine Offal (Prohibition) Regulations during 1991, 1992 and 1993. Where deficiencies were identified these were taken up with the local authority concerned (whose responsibility it was to enforce the Regulations) . . . The instructions to SVS field staff were kept under review and monitoring levels were increased throughout this period . . . In considering the need to intensify the level of monitoring we did not rely solely on the results of the visits carried out by SVS field staff which were reassuring. Rather we took account of all the information reaching us from external sources, some of which suggested that there was a need to probe more deeply.

I met regularly with local authority enforcement interests. These meetings provided an opportunity for both MAFF and the local authorities to raise any issues related to meat hygiene enforcement which were causing difficulty. Although the local authorities had complained about the practical difficulties in enforcing the Bovine Offal (Prohibition) Regulations when these were first made, by the time I took up post in September 1990 these concerns appeared to have disappeared. I do not recall any discussion of these Regulations with local authority interests during the period between September 1990 and April 1994, either at the regular meat hygiene enforcement meetings or on other occasions (such as conferences etc) when I met local authority Environmental Health Officers.

Nor do I recall the meat industry, with whom I met frequently, raising any concerns about the practicality of these Regulations during this period. Many of my industry contacts were very conscious of the need for the slaughtering sector to be seen to be complying fully with the BSE controls, and I believe that they would have alerted me to any widespread deficiencies in the operation of the SBO ban.

I had therefore no reason to believe, prior to April 1994, that the Bovine Offal (Prohibition) Regulations were not proving adequate in practice. When concerns did begin to emerge in 1994, they related to problems of leakage of SBO material back into the animal feed chain rather than into the human food chain . . . ²⁴

5.178 Mr Keith Baker discussed the European Commission inspections to slaughterhouses (discussed in paragraphs 5.20-5.23) and could not recall any comments about inadequate handling of SBO material being made:

Throughout the time I was involved in meat hygiene (i.e. June 1988 to March 1996), there were numerous visits made by Commission Inspectors to study the effectiveness of implementation of Community requirements. Such visits needed considerable preparation, intense involvement during the visits and considerable subsequent action to ensure that such deficiencies as were identified in the Inspectors' reports were rectified. Again, a considerable strain on staff, given the generally uncooperative nature of the industry. Although the Inspectors' detailed reports, produced after each visit, made much of construction and hygiene problems that they frequently identified, I cannot find, or recall, any comments on inadequacies in the way that specified materials were being dealt with. ²⁵

5.179 Mr Du Val of LACOTS told us that prior to 1995, during discussions with the Government about meat hygiene, he recalled no concerns expressed by the Government about the enforcement of BSE controls. ²⁶

5.180 Mr Les Bailey (Senior Executive Officer, LACOTS) provided a joint statement with Mr Du Val. They said:

LACOTS does not formally monitor the effectiveness of enforcement. However, matters of effectiveness may be raised through LACOTS advisory groups or through contact (letter, verbal or at meetings) with government, professional bodies, trade associations or consumer bodies. However . . . as far as staff recall and from a detailed study of LACOTS files [nor] was there any reference to concerns being raised with the organisation about the effectiveness of enforcement of controls relating to BSE. ²⁷

5.181 Mr Etheridge of the Association of District Councils told us that BSE was seldom, if ever, discussed at the regular meetings between the Local Authority Associations and MAFF Meat Hygiene Division:

As I recall, the issues of concern at the time were the introduction of the various pieces of legislation to implement the EC Directives on fresh meat, poultry meat, rabbit meat and game at the time. An ongoing concern about red and poultry meat inspection fees and charges, and charges for residues, and again subsequently a great deal of discussion about the proposed creation of the Meat Hygiene Service. But I cannot recall, but presumably the minutes of those meetings are a matter of record and will confirm that BSE was hardly, if ever, discussed.

MR WALKER: Could I ask this: do you recall any occasion when the Ministry ever sought advice from the Association of District Councils as to how one might check whether SBO enforcement was working?

MR ETHERIDGE: I cannot recall. You have to bear in mind that we were in a climate largely of there being some uncertainty about the efficacy of local authority meat inspection. This is the foundation which led in time to the creation of the Meat Hygiene Service . . . But I cannot recall being approached directly in respect of any failures to enforce adequately the various bovine offal regulations. I mean, in fairness of course it may well be that MAFF did not judge that we had that responsibility, and certainly it is not something that would be automatically considered that would be a role for the associations. ²⁸

5.182 Mr Ashley of the Local Government Association told us that 'large numbers of local authorities did not express concerns over either the disease, the legislation or the Government's overall management of the situation to the LAAs' (Local Authorities Associations). However, he also said this in relation to MAFF's consultation with local authorities on the BSE legislation:

The evolution of BSE legislation was generally characterised by ineffective consultation with the LA Associations. Material appears to have been simply copied to the LAAs for information. True consultation with the LAAs did not commence until the formation of the BSE Regulatory Forum in 1996.

Although Association records no longer exist for much of the period in question, the overwhelming view of staff who were employed at the time supported the view that where consultation was sought, the views expressed were apparently not considered. Certainly with regard to campaigning by member authorities, many individual authorities commented to MAFF that the legislation was flawed and largely unenforceable. ²⁹

Discussion

5.183 We shall see in the next chapter of this volume that, after the establishment of the MHS in 1995, surveillance by the VFS of slaughterhouses resulted in a series of reports of cases where the spinal cord had not been fully removed from meat which had been health stamped. The question arises of why, with one exception, no such instances were reported as a result of the monitoring of the SBO Regulations which we have just described.

5.184 Part of the explanation is that no instructions were given to members of the VFS to pay particular attention to the requirement to remove the entirety of the spinal cord. We have no doubt that they did so once concerns were raised about the removal of spinal cord in 1995.

5.185 We have found that there was a failure to emphasise the importance of the spinal cord both to local authorities and to members of the VFS at the time that the SBO Regulations were introduced (Chapter 3). No substantial consideration appears to have been given thereafter to the desirability of issuing such guidance. We think that this is neither surprising nor a matter for criticism having regard to the apparent equanimity of the Spongiform Encephalopathy Advisory Committee (SEAC) in the face of the information in the paper on slaughterhouse practices (see Chapter 4).

5.186 The next contrast between monitoring visits before and after April 1995 is the extent to which these were truly unannounced. Mr Fleetwood ensured that such visits were truly unexpected after April 1995. He expressed doubts as to whether before that time visits by the VFS would have been unexpected:

If you implement an unannounced visit programme and allow it to run its natural course for a period of time, quite often you will find that the unannounced visit is made every Monday, a pattern of behaviour develops . . . My doubt was not that the slaughterhouse was being phoned and saying I am coming to visit, but merely that the unannounced visits had fallen into a pattern. ³⁰

5.187 Mr Christopher Clark, who had served as a meat hygiene inspector ³¹, told us that it was typical for MAFF VOs on their periodic inspections to arrive mid-morning and depart a few hours later, after discussion with the management of the plant and the principal EHO. ³² Such a visit was unlikely to detect the occasional failure to remove a segment of spinal cord; indeed, this was something that was unlikely to happen if the veterinary officer watched the operation of removing the spinal cord being carried out. If, on average, this failure occurred only in four cases out of 1,000 it is not difficult to see how such instances might have passed unnoticed. Only rigorous inspections of carcasses health stamped and waiting in the chill room would have been likely to bring such shortcomings to light. It seems to us unlikely that such inspections were carried out.