Volume 6: Human Health, 1989-96
6. Events from 1 April to 31 December 1995: human health returns to the agenda
Slaughterhouse surveillance
Hygiene standards during 1995
Instructions issued to the SVS about its new relationship with the MHS
Inadequate staining of SBO during April/May 1995
Concerns raised about the adequacy of spinal cord removal
Report from the first round of SVS surveillance visits to slaughterhouses and head-boning plants between 31 May and 23 June 1995
MAFF Ministers learn the results of the May/June surveillance of slaughterhouses
Discussion of the first round of special surveillance
MAFF and the MHS meet to discuss surveillance results on SBO controls
Preliminary results from the second round of SVS surveillance visits to slaughterhouses and head-boning plants during July 1995
MAFF Ministers learn the preliminary results from the second round of SVS surveillance visits to slaughterhouses
MAFF notifies DH of the preliminary results from the second round of SVS surveillance visits to slaughterhouses
MAFF's consideration of further results from the second round of SVS surveillance visits
Circulation within MAFF and MHS of the final results from the second round of SVS surveillance visits
SEAC discusses the results from the SVS surveillance reports
Report from the third round of SVS surveillance visits to slaughterhouses and other premises dealing with SBO during August/September 1995
Mr Meldrum writes to Dr Calman about the observed failures to remove spinal cord from bovine carcasses
Dr Calman expresses his concerns about BSE to Mr Packer
Discussion: the meeting of 25 October 1995
MAFF and the MHS take steps to tighten enforcement of controls on SBO in slaughterhouses
Mr Hogg meets representatives of slaughterhouses to discuss the handling of SBO
Discussion of the response to the third round of special surveillance
MAFF consults with DH on a paper on BSE and CJD for the Cabinet Committee concerned with the presentation of Government policy
Discussion of Dr Calman's proposed amendment to the Cabinet paper
Dr Calman meets MAFF Ministers to express his concerns about BSE
Mr Hogg announces the results of the September and October SVS surveillance visits to slaughterhouses and other premises
SEAC considers the results of the surveillance visits

Hygiene standards during 1995

6.64 The standards of hygiene in slaughterhouses from January 1991 to March 1995, and the relationships among those monitoring the enforcement of meat hygiene regulations, are discussed in Chapter 5 of this volume. We will now briefly describe and discuss MAFF's growing appreciation of deficiencies both in general meat hygiene and in SBO controls from the time of the introduction of the MHS until the end of 1995. During this period the Bovine Offal (Prohibition) Regulations, which had given effect to the SBO ban under food safety legislation, were revoked and replaced by the Specified Bovine Offal Order 1995, made under the Animal Health Act 1981. The overview at the beginning of this chapter noted that this Order introduced restrictions on the premises where the spinal cord could be removed from the vertebral column of cattle. We note here that the Order also introduced a ban on the removal of brains and eyeballs from bovine skulls other than for scientific or veterinary examination. We shall see later in this chapter how it was stressed that the concerns giving rise to the new Order did not affect the protection of human health. Its main purpose was to tighten the controls preventing bovine offal from reaching animal feed, a topic which is discussed in vol. 5: Animal Health, 1989-96.

6.65 MAFF's appreciation of the standards of hygiene in slaughterhouses at the time of the establishment of the MHS was described by Mr McNeill:

It was made very clear that the major concern was the hygiene standards that prevailed at that time. That was the driving force. It was certainly made clear to me that that was one of the driving forces behind the creation of the new agency. ¹

. . .

MR MATOVU: What were you told about compliance with meat hygiene regulations, beyond the statement that there was a general concern about hygiene?

MR McNEILL: I think it was made clear to me that it was very much a mixed bag: that some premises - some local authorities had maintained a high standard of performance in the premises and ensured high levels of compliance with the fresh meat regulations. On the other hand, others had been less successful in that area of work, but it was very much a mixed bag.

There were at that time available - I think there were broad indications of the HAS scores - the hygiene assessment system's scores - that existed for the premises, and at that time I recollect it was something in the region of circa 30-35 per cent of premises had achieved a HAS score of about 65, which was considered the benchmark indicating compliance with the regulations. ²

Instructions issued to the SVS about its new relationship with the MHS

6.66 SVS and MAFF staff involved with the slaughterhouse industry were given information on the relationship between the SVS and MHS in Animal Health Circular (AHC) 95/40. ³ This explained that the MHS should notify the SVS Divisional Veterinary Officer (DVO) of any defect in compliance with the SBO Regulations in slaughterhouses. After recapping on the various responsibilities and other measures in place on the removal and disposal of SBO, the latest INSET instructions set out the division of responsibilities between MAFF, animal health policy groups and the Veterinary Field Service (VFS). The instructions then set out the arrangements for SVS staff to work with MAFF staff in slaughterhouses and head-boning plants. The instructions for slaughterhouses included the following comments:

Introduction

. . . MHS staff are asked to ensure that SBO is separated, stained, stored and consigned correctly by the operators of slaughterhouses . . .

Responsibilities of SVS staff

DVOs must ensure each cattle slaughterhouse is visited every 2 months, the visit being arranged in collaboration with MHS staff. The purpose of the visit is to discuss with MHS staff the arrangements for disposal of SBO at that slaughterhouse. AHOs may make the visits. At the visit, the following activities must be undertaken:

a) SVS staff should ensure that MHS staff are familiar with the contents of Chapter 10 of the MHS Manual (Appendix 38) and determine from them whether any defects have occurred in the systems or operations intended to separate and dispose of SBO.

b) A tour of the premises should be made in the company of MHS staff, examining in particular:

i. The methods used to separate SBO from material intended for human consumption. . .

ii. The methods use to stain SBO. . .

iii. The methods used to store and consign SBO. . .

c) SVS staff should discuss with MHS staff the checks that have been made to compare the output of SBO with the number of cattle being slaughtered. ⁴

6.67 In oral evidence Mr Peter Soul discussed the changing role of the SVS within slaughterhouses after the introduction of the MHS.

MR WALKER: . . . what did you see as the major change that was brought about when the Meat Hygiene Service became a national agency with national responsibility for meat inspection?

MR SOUL: Yes, in that respect the major change was that the State Veterinary Service took on the role of auditing the performance of the Meat Hygiene Service, compared with their role previously, which was more an advisory role to the then enforcement authority, the local authority.

MR WALKER: That advisory role had been carried out by the Veterinary Officers with special training in meat hygiene. What part did Veterinary Officers play once the National Meat Hygiene Service was in place and operating?

MR SOUL: It was carried out by the Veterinary Officers Meat Hygiene, but also by the RMHAs -

MR WALKER: Yes, they had functional management, as I understand it?

MR SOUL: Yes, yes. Over a period of time, the input from the veterinary officers reduced, and the role of the RMHAs became much more clearly an audit function. That took some time to bring completely into effect. ⁵

Inadequate staining of SBO during April/May 1995

6.68 As well as transferring to central government the enforcement of the ban on SBO in human food, the Bovine Offal (Prohibition) (Amendment) Regulations 1995 ⁶ implemented new staining requirements with effect from 1 April 1995. In order to address concerns of continuing problems with staining of SBO, MAFF issued AHC 95/74 on 19 May 1995. ⁷ This instituted a period of national surveillance whereby all slaughterhouses and head-boning plants that handled SBO would receive an unannounced visit by a MAFF VO. Details of the inadequacies and the MAFF visits can be found in vol. 5: Animal Health, 1989-96.

Concerns raised about the adequacy of spinal cord removal

6.69 On 22 May 1995 Mr Keith Meldrum, CVO, and others in MAFF met to discuss gelatine and, in particular, 'whether skulls and vertebrae should be excluded from its production if it was to be used for ruminant feed'. ⁸ Two days later, Dr Cawthorne informed Mr Peter Hewson (Temporary Head of Meat Hygiene Veterinary Section, MAFF) and Mr Fleetwood of concerns raised at the meeting about the removal of spinal cord from vertebrae. He reported that:

. . . the CVO was anxious to ensure that spinal cord is properly removed from vertebrae during the slaughtering process, that meat inspectors should take particular note of this operation and prevent carcasses/parts of carcasses in which spinal cord was still in evidence in the vertebral column from entering the human/animal feed chains. ⁹

6.70 Dr Cawthorne noted that instructions issued to the MHS regarding SBO collection and disposal did not specifically focus on spinal cord removal, and suggested writing to Mr Phillip Corrigan (MHS Head of Operations) on this as a matter of priority. He also noted that:

Andrew Fleetwood is preparing an amendment to AHC 95/74 issued on 19 May to the effect that SVO staff in the course of their unannounced visits should take particular note on whether spinal cord was being properly removed and emphasise the need for this to be carried out completely to MHS staff. ¹⁰

6.71 In the event, this instruction was issued on 8 August 1995 as part of new INSET instructions to the SVS, as discussed later in this chapter.

6.72 On 2 June 1995 Mr Hewson minuted Mr Corrigan about measures to be taken:

. . . to ensure that spinal cords are properly removed from the vertebral column of beef carcasses. Such removal is essential as vertebrae may be used in gelatin production which may in turn be incorporated in ruminant feed.

MHIs are ideally placed to check on proper removal as the Fresh Meat (Hygiene and Inspection) Regulations 1995 require carcass inspection to take place after carcass splitting. Although I do not believe the same Regulations can be used to withhold the health mark from carcasses which have some spinal cord remaining, MHIs should draw any incomplete removal to the attention of the operator and ensure that the carcass does not leave the premises without the proper removal of the spinal cord being carried out. It is obviously important that the same controls are carried out for condemned carcasses.

SVS staff will be emphasising the need for complete spinal cord removal when they make their visits to check on SBO handling. We would be grateful if you could, in addition, focus the attention of all your staff on their responsibilities in this area. ¹¹

6.73 Accordingly, on 5 June 1995 Mr Corrigan circulated to all MHIs and OVSs an MHS Information Note, entitled 'Removal of bovine spinal cord'. The note stated:

. . . complete removal of the spinal cord from the vertebral column of beef carcasses is required. Such removal is essential as vertebrae may be used in gelatine production which may in turn be incorporated in ruminant feed.

. . .

MHIs should draw any incomplete removal to the attention of the operator and ensure that the carcass does not leave the premises without proper removal of the spinal cord. Equally it is important that the same controls are carried out for condemned carcasses.

I am advised SVS staff will be emphasising the need for complete spinal cord removal when they visit slaughterhouses to check on SBO handling. ¹²

6.74 As we have noted (see paragraph 6.45) the MHS Check List subsequently stressed complete removal of the spinal cord.

6.75 The implications for MRM of incomplete removal of the spinal cord are discussed in the third main section of this chapter.

MHD seeks legal advice on health marking of carcasses in relation to SBO removal

6.76 On 3 July 1995 Mrs Sylvie Sadowski of the Meat Hygiene Division minuted Mr Forsyth of the MAFF Legal Department about the need to remove the spinal cord:

. . . The Fresh Meat Regulations require inspection of the carcase after splitting and MHS staff have been asked to be particularly vigilant that all of the spinal cord has been removed. However we would be grateful for your advice as to whether the MHS can refuse to health mark a carcase from which the spinal cord has not been properly removed.

Regulation 11 of the Fresh Meat Regulations requires that only meat which has been passed as fit for human consumption should be marked. However Schedule 10 does not list contamination with SBO as a reason for unfitness. We seem to rely on the Bovine Offal Regulations which defines excluded matter as any part of the animal which does not consist of or contain any SBO. As I understand it, any part of the animal which contains SBO would be deemed to be SBO and dealt with under the Bovine Offal Regulations (1994 amendment SI 1994/2628). However as the Bovine Offal Regulations prohibits the sale of SBO for human consumption, it would seem reasonable that a bovine health mark should not be applied to any carcase until the inspector is satisfied that all SBO has been properly removed.

Do you consider that 'traces of SBO' (or some other suitable expression) should be included under Schedule 10 as an indication of unfitness? ¹³

6.77 Mr Forsyth replied on 14 July:

Although it is true that Schedule 10 of the Fresh Meat Regulations does not expressly list contamination with SBO as a reason for unfitness for human consumption, I note that paragraph 9 is sufficiently widely drafted to cover such contamination.

It is therefore arguable that the proper removal of the spinal cord is necessary to enable the OVS to be satisfied that a carcase should not be rejected under paragraph 9.

I can of course include a specific reference to SBO in Schedule 10 when I come to draft the amendments to the Regulations in the near future. ¹⁴

6.78 On 31 July 1995 Mr Corrigan followed up the information note of 5 June advising that recent legal advice from MAFF confirmed that, under the 1995 Regulations, the presence of residual spinal cord provided a reason for not health marking bovine carcasses. ¹⁵

Dr Kimberlin proposes a weight audit to monitor SBO removal at slaughterhouses

6.79 Meanwhile, further consideration had been given in June to the removal of spinal cords. On 27 June 1995, Dr Richard Kimberlin, an independent TSE consultant and member of SEAC, wrote to Mr Eddy, ¹⁶ making suggestions for improving the monitoring of the SBO Regulations at slaughterhouses, and focusing particularly on monitoring brain and spinal cord removal, which were considerably more infective than other tissues. He suggested weighing the spinal cord material removed from carcasses as a way of ensuring their thorough removal at the slaughterhouse. ¹⁷

6.80 Mr Fleetwood considered that Dr Kimberlin's suggestion of a separate weight audit for monitoring removal of spinal cord was not necessary. In a minute of 30 June 1995 to Dr Cawthorne, which was copied to Mr Eddy and others in MAFF, he argued against Dr Kimberlin's suggestion and noted:

. . . spinal cord is the one bit of SBO about which we can obtain an absolute guarantee of adequate removal under existing arrangements. The reason for this is that the MHS meat inspector is required to inspect the split half of each bovine carcass before it receives the health mark. It is a simple matter, during this inspection, to check whether the spinal cord has been removed properly. Provided the MHS does its job properly, we can guarantee that each carcass receives a check to ensure that the cord has been removed. ¹⁸

6.81 Having seen a copy of Mr Fleetwood's minute, Mr Eddy considered that MAFF should not dismiss Dr Kimberlin's suggestions. In a minute to Dr Cawthorne on 4 July 1995 he explained that Dr Kimberlin had told him that the BSE subgroup of the EU Scientific Veterinary Committee (ScVC) was seeking an audit approach as a means of demonstrating that the SBO ban was working. ¹⁹ He continued:

I think that we need to be very clear that, not only are we confident that the system is working but that we have arranged things in such a way that we can demonstrate to an increasingly sceptical audience in Brussels, that it is working. Only if we can achieve the latter will we be able to continue to secure the present arrangements which allow British beef to be exported.

. . .

In order to be able to demonstrate that there is no risk to public or indeed to animal health, particularly I suspect the latter, it needs to be shown that all of those spinal cords are properly treated as SBOs and can't end up for rendering or worse for fat reclamation . . . I do get the very strong feeling that he is genuinely trying to help here and that we underestimate at our peril the concern of the Scientific Veterinary Committee about the current situation and the current effectiveness of the SBO controls in the UK. ²⁰

Report from the first round of SVS surveillance visits to slaughterhouses and head-boning plants between 31 May and 23 June 1995

6.82 Mr Fleetwood minuted Mr Meldrum and others in MAFF on 4 July with a summary of the results from the SVS surveillance visits to slaughterhouses and head-boning plants undertaken between 31 May 1995 and 23 June 1995. He stated that the purpose of the visits had been:

To examine the systems used to separate SBO from other material (this includes separation from the carcass, storage and despatch from the premises) and the systems used to stain SBO. ²¹

6.83 He reported that of the 392 slaughterhouses visited 55 were not separating SBO correctly, 33 were not applying the correct stain properly and 83 were not applying any stain. However, with one exception, there had been no instances of failures to separate SBO from material intended for human consumption. Mr Fleetwood concluded:

The overall impression of this snapshot of the industry is that there is widespread and flagrant infringement of the regulations requiring staining of SBO. Insofar as this may reflect the general attitude of the industry to controls on SBO, it is of concern. Although the problems with separation are less extensive, there are grounds for suspecting that the highest risk tissues (brain and spinal cord) have been mixed with other by products and processed for animal consumption. The destination of some of the by-products also process fat into grade 2 tallow and although there is no direct evidence, it is possible that SBO may have been incorporated in products rendered into high grade tallow and subsequently used for human consumption. Apart from these specific problems, a careless attitude to separation and disposal seems to be prevalent and it is probably leading to accidents during disposal.

Reports from the field indicate that most if not all of the problems can be readily corrected, and measures have already been taken to ensure that this happens. There is every reason to believe that matters can be tidied up quickly, given sufficient enforcement activity and a change of attitude by the industry. ²²

6.84 Two days after receiving this report, Mr Eddy raised further issues with Mr Meldrum. ²³ In addition to highlighting the staining problems as a cause for concern, Mr Eddy drew attention to possible problems of contamination of products used for human consumption. He sought Mr Meldrum's views on proposed actions to take in response to the survey:

There are basically two issues to be considered. First, we need to decide what action should be taken to put right the specific problems identified and to ensure that prosecutions can be taken if the situation in the plants is not rectified. Secondly, we need to make sure that the enforcement situation is tightened up: that plant operators have a proper understanding of what their legal obligations are, and that the Meat Hygiene Service have systems in place to ensure they are properly enforced. To address these issues, we recommend that an urgent meeting should be arranged with the MHS to discuss a strategy for correcting the obvious errors quickly and putting in place a programme to ensure education of the plant operators and effective operation of procedures by the MHS. ²⁴

6.85 Further, Mr Eddy considered that:

It may also be necessary, because of the public health implications, to send SVS staff into slaughterhouses every few months to audit the arrangements, at least until we are satisfied that they are being properly applied and enforced by the MHS. ²⁵

6.86 On 11 July Mr Iain Crawford, the Director of VFS, minuted Mr Meldrum, commenting on the surveillance report and Mr Eddy's proposed actions. He expressed concern that 'the picture painted in this report differs to the extent that it does from reports previously received'. He considered it essential for the RVOs to make a detailed investigation of why there was such a difference. He proposed that a possible explanation for the difference was that the report was based on unannounced visits by Veterinary Officers (VOs) who, in comparison with Animal Health Officers (AHOs), 'may have found deficiencies which were not present for announced visits and were also able to ask more searching questions'. Mr Crawford noted suggestions from SVS Field Staff that MHS staff were not fully aware of SBO requirements, and that such awareness was essential 'in view of their front line role'. He endorsed Mr Eddy's suggestion of a meeting with senior MHS staff. ²⁶

6.87 On the same day, Dr Cawthorne sent an Animal Health Circular to DVOs requesting immediate submission to SVS Headquarters of completed reports from follow-up visits to slaughterhouses and head-boning plants where problems had been identified in the May/June survey. Reports from any remaining follow-up visits were requested to be sent on a weekly basis. ²⁷

MAFF Ministers learn the results of the May/June surveillance of slaughterhouses

6.88 On 13 July 1995 Mr Packer put forward a submission on the results of the SVS surveillance of the SBO controls in May/June to Mr Douglas Hogg (the new Minister of Agriculture ²⁸) and to Mrs Angela Browning (Parliamentary Secretary, MAFF ²⁹). He also attached a submission reporting on the consultation on the proposed Specified Bovine Offal Order. ³⁰

6.89 His covering minute noted that:

I think the papers make a convincing case to the effect that measures already in place properly protect human health. However, taken together they seem to me to present real problems of presentation. It may be regarded as unfortunate, for example, to be continuing to introduce more stringent requirements about the treatment of bovine skulls. We do, of course, know now, which we did not know previously, that a very small amount of infected brain can bring about the disease if fed orally, but even so this explanation might not seem wholly convincing to some who might consider the situation should have been properly grasped long since. Equally, the unsatisfactory treatment of specified bovine offal in slaughterhouses reflects an unfortunate state of affairs which has presumably existed for many years. We must expect questions on why we allowed this situation to persist for so long. ³¹

6.90 During oral evidence Mr Douglas Hogg was asked what his explanation was for the state of affairs as outlined by Mr Packer. He responded:

I know that until the Meat Hygiene Service was set up, it was the responsibility of local authorities acting through the Environmental Health Officers. We set up . . . the Meat Hygiene Service in April, I think it was, 1995, and it was only at that point that we really began to get a proper fix on what was happening in the slaughterhouses. I am bound to say that looking back, it does not surprise me that the Environmental Health Officers were not policing it as effectively as they should have done, but we only got a fix on that when the Meat Hygiene Service was established. ³²

6.91 When asked why it did not surprise him that Environmental Health Officers were not enforcing the regulations, he answered:

Because they answer to many separate authorities and do not answer to one . . . Giving a formal instruction, which was under the framework agreement . . . is a very rare thing because it is a re-ordering of priorities. I could do that when we had the Meat Hygiene Service. It was utterly impossible to do it when the Environmental Health Officer is responsible to the Chief Executive of many a council, so there were advantages. ³³

6.92 The submission put forward by Mr Packer to Mr Hogg recommended that:

Urgent action, already in hand, should be pursued to rectify failures in separation and staining of SBOs in slaughterhouses, with prosecutions if necessary; action is also in hand to improve enforcement action. It is recommended that the results of the surveillance should be made publicly available. ³⁴

6.93 It also drew attention to the implications of the observed failures of the SBO controls for BABs. ³⁵ In particular the submission stated:

Since there is scientific evidence that BSE can be transmitted to both calves and mice experimentally by consumption of very small quantities of infected material, failures at the slaughterhouse are likely to show through in continuing cases of BSE in animals born after the introduction, in July 1988, of the ban on feeding ruminant protein to ruminants. ³⁶

6.94 Comments were also made on the implications of the survey results for human health. In particular:

The circumstantial evidence that there might have been indirect contamination of products for human consumption, as a result of material being included in rendering for high grade tallow should not be overstated. Even if this were to be the case (which we cannot prove) the processing itself would be effective in destroying any contamination. The implications of the failures in the controls are therefore for animal health, not human health. Ministers have based the reassurance they have provided to consumers on the fact that the UK legislation effectively prevents any potentially infective material from entering the human food chain. It is therefore essential that any potential problems of control in this area are resolved immediately. ³⁷

6.95 On 18 July 1995 Mr Hogg held a meeting with Mrs Browning, Mr Packer, Mr Eddy, Mr Meldrum, Mr Martin Haddon (Animal Health Group), Mr Fleetwood and several other MAFF officials to discuss the submission. ³⁸ The note of the meeting recorded that, with regard to the deficiencies in the handling of SBO in slaughterhouses, Mr Meldrum had reiterated that 'there was no public health problem, there was no question of SBOs entering the human food-chain, the risk was of cross-contamination of animal feed'. Mr Hogg agreed that unannounced visits to slaughterhouses to check compliance should continue.

6.96 At the meeting Mr Hogg also agreed to announce the results of the survey of slaughterhouses by way of a Parliamentary Answer along with 'a low-key background press briefing' by Mr Meldrum. As part of the discussion on handling at the meeting, the note recorded that 'it was important that the Department of Health were fully in the picture and that the CMO would if necessary reiterate that there was no public health implications'. ³⁹

6.97 The next day MAFF issued a press release on the new SBO Order and the survey results. Entitled 'Tightening the rules on BSE', it contained the text of a Parliamentary Answer from Mr Hogg. It opened with the following remarks:

A strengthening of the rules for preventing tissue potentially infected with the BSE agent from entering the cattle feed chain was announced today by Agriculture Minister Douglas Hogg. The Ministry has also indicated that there is room for improvement in the application of the current rules in some slaughterhouses and further action is under way to deal with this.

Mr Hogg emphasised that there were no implications for the human feed chain in these findings and that measures to protect human health were found to be working effectively in all cases. ⁴⁰

6.98 Mr Hogg concluded the Parliamentary Answer with the following:

Although these lapses in our animal health control system are unsatisfactory, consumers have no cause for alarm. I am satisfied that these findings have no implications for human health and that measures to ensure that no infective material enters the human food chain are working effectively. ⁴¹

Discussion of the first round of special surveillance

6.99 The fact that no shortcomings were reported in relation to the operation of removing SBO from the carcass was in line with earlier SVS surveillance reports and gave a falsely reassuring picture. We note, however, that prior to this first round of special surveillance no instructions were given to pay particular attention to the removal of spinal cord.

6.100 The reports of failures to remove spinal cord that were a feature of the second and subsequent rounds of special surveillance resulted, we believe, from the focusing of attention on the importance of the removal of spinal cord. Even before the new inset instructions were issued on 8 August (see paragraphs 6.71 and 6.119), we have little doubt that concerns that were being expressed about the removal of spinal cord would have led to the importance of this being drawn to the attention of the members of the VFS who were carrying out slaughterhouse surveillance.

MAFF and the MHS meet to discuss surveillance results on SBO controls

6.101 On 18 July 1995 Mr Meldrum, Mr Crawford, Mr Haddon, Mr Kevin Taylor (Assistant CVO), Dr Cawthorne, Mr David Taylor (Veterinary Head of Section, Red Meat Hygiene Section) and Mr Eddy met with Mr McNeill and Mr Corrigan of the MHS to discuss SBO controls in licensed fresh meat premises. They considered the recent results from the SVS survey of slaughterhouses and the MHS HAT visits:

Those visits indicated that both separation and staining of SBOs was lacking at a significant number of premises. These findings have been confirmed at HAT visits made to a smaller sample of slaughterhouses by the MHS. Neither of these surveys found any cause for public health concern in relation to SBOs. ⁴²

6.102 It was agreed that where an SVS visit had found an unsatisfactory situation, the following course of action would be followed:

a) A second visit would be made and any deficiencies would be confirmed in writing to the MHS Head of Operations copied to the MHS Regional Manager.

b) The Head of Operations would then confirm the deficiencies to the management of the premises, copied to the OVS. This letter would need clearing by Legal as it would formally warn of a third unannounced visit and threaten a prosecution if deficiencies remained.

c) The third visit would be made by an RMHA or VO accompanied by a POVS. If serious deficiencies remained details of non-compliance would be noted and Investigation Branch would be requested to take the case on.

d) If Investigation Branch recommended prosecution, Ministers would need to be consulted prior to any further action being taken. ⁴³

6.103 Mr Fleetwood referred to Mr Hewson's minute in a statement to the Inquiry:

I see also from Mr. Hewson's minute of 18 July 1995 that visits to slaughterhouses by hygiene audit teams (HAT) carried out by staff of the Meat Hygiene Service were discussed at that meeting. I do not believe I was previously aware of the HAT programme. Certainly, I do not recall there being any consistent flow of information back to me from the Meat Hygiene Service about their own findings when inspecting slaughterhouses. The information flow seemed to be largely one way - with MAFF reporting to the Meat Hygiene Service the findings of checks carried out by SVS staff. ⁴⁴

Preliminary results from the second round of SVS surveillance visits to slaughterhouses and head-boning plants during July 1995

6.104 The SVS followed the May/June survey with a second round of visits to slaughterhouses during July 1995. Mr Fleetwood reported the preliminary results to Mr Corrigan of the MHS and to others in MAFF on 28 July 1995. ⁴⁵ Various problems were identified by the visits, but in particular Mr Fleetwood identified two operators that had not properly removed SBO from material for human consumption. At the first operator, spinal cord had been seen in one carcass, and tonsils were not properly removed from heads. At the second operator, brains had been removed from heads, and then 'brought back into the human consumption part of the factory for vacuum packing'. ⁴⁶ Mr Fleetwood said that these two operators:

. . . are posing a risk of contamination of material for human consumption and the problems must be corrected immediately by whatever means necessary. SVS staff gave advice at the time of their visit, but we must know if that advice has been acted on. We would be grateful if you would assign immediate priority to these premises and keep us informed of developments. ⁴⁷

6.105 Mr Fleetwood advised Mr Corrigan that the MHS should take the lead on the follow-up visits, with SVS staff in attendance to report on the outcome. Mr Fleetwood also advised that visits should be undertaken so evidence could be collected for a prosecution, if necessary. ⁴⁸

6.106 The results from these SVS surveillance visits to slaughterhouses in relation to SBO removal between July 1995 and March 1996 are given at Annex A of this chapter.

MAFF Ministers learn the preliminary results from the second round of SVS surveillance visits to slaughterhouses

6.107 On 1 August Mr Eddy minuted Mrs Browning and other MAFF Ministers regarding the preliminary results from the second round of SVS surveillance visits. Mr Eddy reminded Mrs Browning of the assurances MAFF had made in the news release issued after the first round of visits, in particular that the problems found 'had no implications for human health, because none of the lapses could have resulted in infective material entering the human food chain'. ⁴⁹ He drew attention to the two operators who had been found to be failing to separate SBO properly from material for human consumption (see paragraph 6.104). He advised that the SVS was undertaking follow-up visits to these two operators to investigate further, and continued:

Farming News on 28 July reported on the deficiencies mentioned in the Parliamentary Answer, suggesting that if potentially contaminated material had been allowed to leak into the animal feed chain, then it was likely that the same thing was happening in the human food chain. The two instances we have now found mean that we cannot respond to that article in such robust terms as we could have done on the basis of the first round of visits.

Subject to further clarification on the problem at the two plants we can no longer maintain publicly that our visits to slaughterhouses have shown no implications for human health. I would advise against an immediate response to Farming News. We need to investigate the two reports in greater detail to clarify whether the circumstances were such as to suggest there was a genuine risk to human health. ⁵⁰

6.108 In a statement to the Inquiry, Mr Hogg said:

At first sight these were serious problems which if undetected could have led to SBOs entering the human food chain, although this was by no means clear. SVS staff gave on the spot advice to the operators to correct the problem, and both plants were to be visited again. I was concerned that there was a potential risk of SBOs entering the human food chain and was determined to continue promoting the proper enforcement of SBO controls. ⁵¹

6.109 On 2 August 1995, Mrs Elizabeth Ratcliffe, Private Secretary to Mrs Browning, informed Mr Eddy that 'the Parliamentary Secretary has commented that immediate action is necessary to correct these problems'. ⁵²

6.110 On 7 August Mr Eddy updated Mrs Browning on action taken:

The results of all the unsatisfactory visits have been taken up with the Meat Hygiene Service, who are responsible for enforcement, to take immediate action to get the various problems corrected. We asked for top priority to be given to immediate correction of the problems in the small minority of slaughterhouses where there was a risk of contamination of material for human consumption. This has been done, and those practices have ceased. ⁵³

On the minute Mrs Browning's Private Secretary wrote on behalf of Mrs Browning that she wanted to be alerted to any problems that arose in relation to this or any other BSE-related matter. ⁵⁴

6.111 Mr Eddy had been advised on 4 August of Mr Hogg's concerns about the preliminary results from the second round of slaughterhouse visits. Mr Strang (Principal Private Secretary to Mr Hogg) noted that in particular 'the case involving spinal cord could be very serious'. ⁵⁵ He advised that Mr Hogg had agreed that MAFF should pursue the approach as outlined by Mr Carden (Grade 2 Head of MAFF's Food Safety Directorate):

1. tightening up the rules whenever there was evidence that action was needed;
2. tightening up enforcement;
3. making prosecutions when companies repeatedly infringed the legislation.
4. The Minister commented that we should certainly not shrink from (iii). ⁵⁶

MAFF notifies DH of the preliminary results from the second round of SVS surveillance visits to slaughterhouses

6.112 DH was notified of the surveillance results on 3 August 1995 when Mr Eddy minuted Mr Charles Lister (responsible in DH for administrative aspects of BSE). ⁵⁷ Mr Eddy advised that as a result of the observed failures of SBO separation 'there has been an immediate crack down, and the problems found have been put right'. He continued:

We can no longer be as robust as we were in the press notice about no infective material entering the human food chain, but the problems are not such as to warrant a special announcement or any special new measures other than the immediate action that was taken at the plants concerned. We are considering how the situation should be handled. I am inclined to await the results from the third round of unannounced visits, which should be with us in the Autumn, before advising on any further announcements. I do not see it as necessary to issue press statements at every stage in what is a three stage process. I would welcome DH's views. ⁵⁸

6.113 The next day Mr Lister copied Mr Eddy's letter to Dr Ailsa Wight (Health Aspects of the Environment and Food Medical Division, DH), stating that Dr Calman and DH Ministers needed to be briefed on the findings. He said:

SEAC will clearly need to discuss the implications at the next meeting, but it comes down, as always, to the need for adequate policing of slaughterhouse practices. Once all the visits are completed - there is a third series to come in the Autumn - we will need to consider how the results affect our assurance to the public that, following the SBO ban, no potentially infective material can enter the human food chain. ⁵⁹

6.114 On 25 August 1995 Mr Meldrum wrote to Dr Jeremy Metters, Deputy CMO, regarding Mr Eddy's letter to Mr Lister. Mr Meldrum said that in his view Mr Eddy painted a 'more alarmist picture than is justified by the circumstances'. Although many faults had been found, 'there was no risk to public health in any of the three cases because each was spotted and corrected'. He said:

It is, of course, true that there may be other undetected cases where SBO is not properly removed and destroyed, but this has always been the case and is still the case now. The argument for strict enforcement is clear, the Meat Hygiene Service is aware of it, and the new SBO legislation which has just been introduced, although primarily directed to protecting the health of cattle, should simplify their task in some respects. The Meat Hygiene Service has issued specific and detailed instructions to its staff on the checks that must be carried out to ensure compliance with our legislation. ⁶⁰

6.115 Dr Metters replied on 1 September that it was 'helpful to have this amplification' and that, as Mr Meldrum's letter had noted, 'this strengthens the case for strict enforcement by the Meat Hygiene Service'. Dr Metters also noted that there were plans to report the latest results at SEAC's next meeting and that 'both our Departments will benefit from having an up-to-date comment from SEAC'. ⁶¹

6.116 Dr Calman received copies of the correspondence between Dr Metters and the CVO. In a statement to the Inquiry he noted:

The critical issue was whether the three instances set out above were isolated incidents, or whether they were indicative of a wider problem. That question would only be fully answered by a careful examination of the results of the further round of unannounced visits. ⁶²

MAFF's consideration of further results from the second round of SVS surveillance visits

6.117 On 3 August Mr Fleetwood updated others in MAFF on the latest results from the second round of visits. ⁶³ He noted problems of SBO separation in 13 of the 166 plants visited, and commented:

As regards separation, most of the recurring problems concern mixing of SBO with other unfit material. However, there was evidence that SBO was not being separated adequately from material for human consumption at three premises. ⁶⁴

6.118 We have described the problems at two of these premises above in paragraph 6.104. The minute noted that two slaughterhouses, which had previously been found to not be removing SBO adequately, had now corrected their processes. However, the problems at a third plant were described as follows:

The inspecting VO had found that a new slaughterhouse hand was not adequately separating tonsil from the head. All the heads in the plant were examined by the VO and all the tonsil tissue seen to be removed. The OVS and plant operator were informed of the problem and a follow up visit by the VO revealed that the problem has been corrected. ⁶⁵

6.119 On 8 August 1995 MAFF circulated AHC 95/119 to DVOs and other SVS field staff, providing instructions for the visits to be undertaken to all plants where deficiencies had been discovered during the second round of visits. ⁶⁶ SVS staff were instructed to undertake follow-up visits in respect of SBO with MHS staff. On the same day, MAFF also issued INSET 25A under cover of AHC 95/118. ⁶⁷ Section D5 of the new INSET explained that SVS staff, in the course of their routine visits to slaughterhouses, should examine among other things:

. . . the methods used to separate SBO from other carcass material. Particular attention should be paid to ensure that spinal cord is completely removed from the vertebral column. Checks can be made both on the slaughter line and in the chiller room. ⁶⁸

6.120 Also on 8 August, Mr Fleetwood wrote to Mr Soul of the MHS, enclosing AHC /95/119 and noting:

. . . we need to clarify exactly what action is and will be taken by the MHS in respect of those premises which have recorded unsatisfactory results. This is particularly important in the light of the fact that Ministers are expecting a robust and co-ordinated response and have indicated to us that they do not want the MHS to shrink from taking prosecutions against those companies who do not put their house in order within a reasonable time.

6.121 Mr Fleetwood included a table in his minute that recorded the second round visit results on separation of SBO at 214 slaughterhouses as 'All OK'. Fifteen were recorded as 'Not OK'. He noted that:

as problems with separation of SBO are likely to have more serious consequences than problems with staining, and as the number of premises involved is small, I think it would be advisable for the MHS to target these premises in the strongest possible manner. They may well be potential candidates for prosecution, along with those operators who have refused to obtain the correct stain. ⁶⁹

Circulation within MAFF and MHS of the final results from the second round of SVS surveillance visits

6.122 On 22 August 1995 Dr Cawthorne sent Mr Meldrum, Mr K Taylor and others in MAFF and the MHS a summary of the final results from the second round of SVS visits to slaughterhouses. ⁷⁰ Dr Cawthorne reported that of the 272 premises visited there were problems in relation to SBO controls at 74 plants, while controls were satisfactory at the other 198. Of the 74 plants with problems there was inadequate separation of SBO in five, ineffective staining in 59 and inadequate separation and staining in 10. He also reported that the three plants identified with SBO separation problems in the preliminary results circulated earlier that month had corrected those problems.

6.123 Dr Cawthorne also reported that Mr Corrigan and MHS Regional Managers had undertaken to provide a statement identifying for each of the 74 plants where inadequate separation and staining was detected:

. . . to identity whether (a) the inadequacies had been corrected, (b) if they have not been corrected, why not, identifying mitigating circumstances, and (c) identify plants which were candidates for prosecution. ⁷¹

The aim was to have this information available in time for the next SEAC meeting.

6.124 We described in the first main section of this chapter the circulation within MAFF on 23 and 24 August 1995 of the Eville & Jones report, and the comments that it evoked.

SEAC discusses the results from the SVS surveillance reports ⁷²

6.125 On 8 September 1995 SEAC discussed the results of SVS visits to slaughterhouses. The meeting was recorded in Mr Eddy's minute of 11 September 1995 to Mr Meldrum:

Mr Fleetwood gave a very clear and convincing exposition of the findings from the final round of intensive visits. The Committee were reassured by the progress from the first round of visits and the fact that we were continuing to visit on an unannounced basis. They accepted that we now had a grip on this but the point was made that it would have been better to have done this five years ago and we will clearly have major problems with the Committee unless we can give them constant reassurance that we are keeping up the pressure and that there has been no back sliding. ⁷³

6.126 However, Mr Eddy also noted that the Committee wanted to know:

What happens to any spinal cord removed as a remedial measure by the abattoir staff or inspectorate in the cold store or elsewhere in the meat plant where sides are inspected for the health stamp? There was concern that these spinal cords might not be specially transported back to be reunited with the other spinal cords and could possibly end up in scraps which would go for animal feed. ⁷⁴

6.127 Following his attendance at the SEAC meeting, Mr Fleetwood wrote to Mr Corrigan on 18 September 1995, noting that SEAC, in 'welcoming the progress made', asked that it be 'sustained by the MHS and the SVS'. He also mentioned SEAC's concern about fragments of spinal cord being disposed of incorrectly, and said that SEAC 'asked that the MHS should draw this to the attention of their staff in individual plants, asking them to ensure that all such fragments are collected together and included in the weight audit'. ⁷⁵

6.128 On 20 September 1995 Mr Corrigan sent a memorandum to all MHS staff echoing Mr Fleetwood's minute. ⁷⁶

6.129 Mr Corrigan sent a further memorandum to all MHS Regional Managers on 26 September 1995, noting that the SVS second round of visits had been completed and that Mr Corrigan had been advised that any outstanding problems had been rectified. He reported that the SVS had been instructed to carry out further unannounced visits and stressed the necessity of paying attention to the SBO controls. ⁷⁷

6.130 We described in the first main section of this chapter the meeting of 5 October 1995 at which it was agreed that Mr Swann would act as editor for the section of the HAT report dealing with red meat audit.

Report from the third round of SVS surveillance visits to slaughterhouses and other premises dealing with SBO during August/September 1995

6.131 On 6 October 1995 Mr Fleetwood minuted Dr Cawthorne, with copies to others in MAFF and the MHS, regarding the results of SVS surveillance visits undertaken during August/September 1995. Mr Fleetwood recorded that 14 of the 193 slaughterhouses visited had revealed deficiencies in relation to 'identification, removal or separation of SBO', and 48 per cent of total visits to these premises had been unsatisfactory. He noted, 'The results show a less than satisfactory outcome. I am particularly disappointed with the high failure rate at slaughterhouses, especially in view of the recent efforts made by the SVS.' ⁷⁸

6.132 Mr Fleetwood considered that the results from the slaughterhouse visits raised questions about the MHS:

Our findings in slaughterhouses also raise questions about the MHS. I do not believe that we should find ourselves in the position of detecting a 48% failure rate on random inspections when MHS enforcement staff are in these premises on a regular basis. The information gathered by the field would allow performance indicators to be set down . . . For instance, we could set an indicator of no more than 1% failure rate on SVS routine inspections. ⁷⁹

6.133 On 12 October Mr Fleetwood minuted Dr Cawthorne regarding the outcome of his enquiries into possible reasons for the unsatisfactory results at slaughterhouses. He reported that several VOs had found evidence of inadequate spinal cord removal, one VO reporting '6-9 inch lengths in some cases'. ⁸⁰ Mr Fleetwood noted that the 'problems with spinal cord are potentially serious and it is clear that our staff are not overemphasising the problems in this respect'. ⁸¹

6.134 Mr Eddy, who had received a copy of the minute, commented on the observations of Mr Fleetwood in a statement to the Inquiry:

With the benefit of hindsight the fact that these allegations were made suggests that those directly involved in enforcement work in slaughterhouses may have been applying a degree of tolerance of minor failings which I do not believe was ever asked of them in their instructions. ⁸²

6.135 On 13 October 1995 Dr Cawthorne updated Ministers on the results from the third round of SVS surveillance. He noted that 'no problems were identified that could present a public health hazard' but that the results were nevertheless 'disappointing'. He continued:

Some of the failures with separation reflect genuine, continuing problems and the MHS will be contacting Investigation Branch with a view to obtaining evidence to support a prosecution. However, no prosecution would be taken without the consent of Ministers because such action could undermine the validity of our BSE controls.

. . .

The CVO has expressed his concern over these results to MHS senior management in a meeting earlier this week who, in turn, have acknowledged that faults by plant operators are still evident though not on the scale recorded earlier in the year and not always of the same degree of concern. They have instituted a programme of management checks on their own staff to ensure full compliance and included in this package, disciplinary or enforcement action where this is considered necessary. ⁸³

6.136 On 20 October 1995 Mr Soul wrote to MHS Regional Managers informing them that SVS staff were continuing to find cases of beef sides where the health mark had been applied, and yet pieces of spinal cord were still present in the spinal canal. Mr Soul asked all plant-based staff to be made aware that they must not permit the health mark to be applied until all the spinal cord had been removed. ⁸⁴ A schedule of the observed failures of spinal cord removal up to 1 March 1996 is attached at Annex A. There was some delay between local reporting of such failures and their coordination and reporting at national level.

Mr Meldrum writes to Dr Calman about the observed failures to remove spinal cord from bovine carcasses

6.137 On 23 October 1995 Mr Meldrum wrote to Dr Calman enclosing a proposed reply to a Parliamentary Question from Mr Martyn Jones (Labour MP, Clwyd South West) on the possible entry of SBO into the human food chain. He reported that the findings of the SVS staff's bi-monthly audit had shown four cases where spinal cord was found attached to carcasses. He commented that 'in all cases, an unannounced visit, approximately a fortnight later, showed that spinal cord was being removed correctly and in its entirety'. He continued:

These findings are disappointing and I am shortly to have a meeting with the industry to impress upon them the importance of compliance with the requirement to fully separate and dispose of SBO. We can never guarantee that bone tunnels will not occur when the carcasses are split and that pieces of spinal cord will then remain hidden from view. It is quite clear that our veterinary staff are alert to this particular aspect of SBO separation and are identifying a small number of cases where residual cord is being found.

6.138 Though measures were being taken to correct the problem, Mr Meldrum considered that such failures were inevitable to a certain degree as 'no system operated by humans can deliver at 100% efficiency all the time'. ⁸⁵

6.139 In the Written Answer to Mr Jones's Parliamentary Question, which was published the next day, Mrs Browning stated:

Since 1 April 1995 the Meat Hygiene Service has been responsible for enforcement of the controls. We know of no instances where SBOs have entered the human food chain. We are aware of four cases where small amounts of SBO had been left attached to carcasses after dressing but these were properly removed before the carcasses left the premises. ⁸⁶

6.140 In a statement to the Inquiry, Sir Kenneth Calman said that Mr Meldrum's opinion that the findings were 'disappointing' had understated the importance of the information. ⁸⁷ He then described his concern at receiving Mr Meldrum's letter:

Since the ban on both the human consumption or use of SBOs, I and the Department of Health and its advisers were relying on the fact that a system of inspections to ensure this ban was observed in practice had been instituted by MAFF. Notwithstanding the fact that primary responsibility for compliance with the relevant legislation lay with those owning and operating slaughterhouses, cutting rooms and cold stores, the Department of Health and others including SEAC had always proceeded, (after the introduction of the legislation), on the basis that such bans were both in place and effective. Enforcement of all legislation relating to animal health fell within MAFF's jurisdiction.

My concerns related to the fact that until the end of October 1995 I, the Department of Health, and others including SEAC had repeatedly made statements in relation to the consumption of beef and its risks to human health and BSE based upon the fact that: -

(1) Legislative bans on potentially infected tissue were in place and effective

(2) There was currently no scientific evidence of a link between meat eating and the development of CJD. ⁸⁸

6.141 Mr Meldrum discussed Dr Calman's statement in his oral evidence to the Inquiry:

I was particularly concerned at the suggestions and the suggestions came really from elsewhere that in 1994 and 1995 there was a lack of communication between ourselves and the Department of Health. So far as I am aware the major submissions to Ministers leading up to the change in the controls on SBOs were copied to the Department of Health. So that they were aware of the problems particularly in August 1994 and subsequently I attempted to keep Sir Kenneth informed.

Lastly, I would just say I was a little bit surprised when he expressed his surprise in his statement about the letter I wrote to him on 23 October 1995. On its own, yes, I can understand his concern but there had been some earlier discussions with Sir Kenneth which he may have forgotten about for the moment when I expressed to him my personal concerns about the SBO controls prior to a meeting that took place with the Meat Hygiene Service on 11th October 1995, when, if you like, I expressed my extreme displeasure at the fact that there were significant problems with the SBO controls and I asked Johnston McNeill and Peter Soul to do everything they possibly could to achieve full compliance. I had thought that Sir Kenneth was aware of that meeting and my concerns at that time. ⁸⁹

6.142 On 24 October 1995 Mr Lister informed Dr Kenneth Calman that SEAC had discussed the removal of SBO on 8 September 1995. He explained that the question of whether small scraps of spinal cord might get into the human food chain was raised, but that MAFF 'saw this as a problem affecting only the animal food chain and one which the new Meat Hygiene Inspections would resolve'. He continued that the information presented in the answer to the Parliamentary Question was new, and not available to SEAC, and summarised the evidence as follows:

Continuing cases of BSE in animals born after the feed ban indicate that SBOs may well have got into animal feed because of inadequate controls at slaughterhouses. We cannot therefore rule out the possibility that SBO may have got into the human food chain. This concern is supported by evidence from the recent unannounced visits to slaughterhouses; but

New MHS inspection system means that the situation is now being controlled and opportunities for contamination should become rare. However, we can't yet say that the problem is resolved, and this concern is shared by the SEAC. ⁹⁰

6.143 Dr Wight and Mr Lister had discussed the wording of a CMO statement, and proposed the following:

In view of the uncertainty surrounding slaughterhouse procedures, it is impossible to give a complete assurance that Specified Bovine Offal has not entered the food chain. However, it is exceedingly unlikely that this has happened to any great extent and, importantly, I remain satisfied that there is no scientific evidence of a link between meat-eating and the development of CJD in humans. ⁹¹

Dr Calman expresses his concerns about BSE to Mr Packer

6.144 Sir Kenneth Calman was 'extremely concerned' ⁹² about Mr Lister's report, and on 25 October 1995 he met Mr Packer and Mr Carden to 'express disquiet about the position on BSE'. ⁹³ There is a conflict of evidence about this meeting. Mr Packer briefed Mr Hogg on the meeting, and set out Sir Kenneth's concerns as follows:

the continuing high number of BSE cases found, though admittedly this was declining;

the fact that many cases had been 'born after the ban' (that is after the ban on the inclusion of ruminant protein in ruminant feed). He noted that MAFF now accepted that for many years controls in feed mills and elsewhere had been insufficient to prevent ruminant protein being included in ruminant feed;

the recent discovery as announced by Parliamentary Answer that spot checks had shown that Specified Bovine Offal was not always properly removed in slaughterhouses. (As the CMO also pointed out such was in any case suspected since otherwise, even if ruminant protein had been included in ruminant feed, it ought not to have been capable of producing BSE . . .);

the fact that four farmers all with BSE in their herds had now contracted CJD. The chances of this occurring naturally were very small indeed;

the fact that the Department of Health had not been properly consulted about the PQ we had recently answered on the failures in slaughterhouses. The CVO had sent him a draft at a late stage but the reply had been laid before he had been able to comment. This did not help confidence between departments. ⁹⁴

6.145 Mr Packer continued that against these concerns the CMO had agreed:

. . . that the scientific work undertaken so far had been reassuring about the possibility of transmissibility to man; and there was still a strong balance of probability against the consumption of beef being related to CJD. However, overall he was not entirely happy with the situation and this would inevitably be reflected in his public utterances. While he would not depart drastically from what he had said previously and, in particular, would continue to maintain a strong presumption as to the safety of beef, he could not be as unequivocal as in the past. ⁹⁵

6.146 Mr Packer noted that he had offered assurances to Dr Calman that MAFF would ensure they liaised with DH on matters such as Parliamentary Questions and would pursue with vigour the monitoring of adherence to the Regulations in slaughterhouses. In relation to further action, Mr Packer proposed to Ministers that MAFF should call in the slaughterhouse owners and 'read the riot act'. He reported that the CMO had suggested it would be helpful if he met the Minister to express his concerns. ⁹⁶

6.147 On 25 October 1995 Dr Calman set out his concerns in a confidential file note. He noted that information available over the last four months necessitated a review of the existing evidence that there was no link between BSE and CJD. The new information related to the incidence of CJD provided by the CJD Surveillance Unit, the lack of a rapid fall-off in the incidence of BSE in cattle, the possibility that SBO might get into the food chain from slaughterhouses, and greater understanding of the biology of BSE. His note continued:

These findings taken together do not give grounds for complacency and are not entirely reassuring. The uncertainty remains, and may even have increased. In view, in particular of the problems uncovered in the slaughterhouse procedures, it is impossible to give complete assurance that SBOs have not entered the food chain. However, it is exceedingly unlikely that this has happened to any great extent, and importantly there remains no scientific evidence of a link at present between the eating of meat and the development of CJD in humans. These conclusions have been confirmed by SEAC. The long incubation period needs to be remembered.

The issue remains however, that the uncertainty has increased, rather than decreased. Urgent action is required to reassure the public that all steps are, and have been taken, to minimise any possible risk. ⁹⁷

6.148 Mr Hogg read Mr Packer's minute describing the meeting with Dr Calman 'with concern' and asked for 'an urgent meeting' with officials and a separate meeting with the CMO. ⁹⁸

Discussion: the meeting of 25 October 1995

6.149 During oral evidence to the Inquiry, Dr Robert Kendell, CMO for Scotland, ⁹⁹ said that he attended the meeting between Dr Calman and Mr Packer. However, he recalled the meeting being attended by five or six people at Richmond House in the room next to Dr Calman's office, whereas Mr Packer's minute says 'the Chief Medical Officer and a colleague came to see Mr Carden and me earlier today'. ¹⁰⁰ Dr Kendell said that Dr Calman made his concerns very clear, and that:

Mr Packer explained that we needed to understand that farming was a fairly anarchic industry, and that slaughterhouses were under great economic pressure. They knew that some of them were going to go out of business. And it was almost inevitable that these regulations would not be fully observed all the time. ¹⁰¹

6.150 Dr Kendell also suggested that the meeting was 'heated', and that Dr Calman was 'upset and cross'. When asked whether he thought the lapses in adherence to the SBO Regulations had come as a surprise to Dr Calman, Dr Kendell explained:

I think he had known for perhaps a week or two, but not for longer than that, about these failures of Meat Hygiene Service inspections. But I think the thing that was distressing was not the magnitude of the breakdowns - we thought that we were talking about four or five or six occasions on which an inspector had found spinal cord still attached to a carcass - but it was this attitude, 'Well, you have to expect this', that upset us. ¹⁰²

6.151 In a statement to the Inquiry, Mr Packer asserted:

I recall the meeting on 25th October and I believe I would remember such comments (had I made them) and such a reaction from Sir Kenneth. I recall neither. ¹⁰³

6.152 Mr Packer also suggested that a number of inconsistencies between Dr Kendell's evidence and the contemporaneous minute existed, and suggested that 'Dr Kendell's recollection must be incorrect'. ¹⁰⁴

6.153 We have not been able to reconcile details of Dr Kendall's evidence ¹⁰⁵ with the other evidence relating to the meeting on 25 October and are left in doubt as to the reliability of his recollection of the comments that he has ascribed to Mr Packer. Mr Packer's actions in the day that followed certainly displayed no complacency (see paragraph 6.144).

MAFF and the MHS take steps to tighten enforcement of controls on SBO in slaughterhouses

6.154 On 27 October 1995 Mr Eddy put forward a submission to Mr Hogg on measures to tighten enforcement of controls on SBO in slaughterhouses. He invited Mr Hogg to note that the SVS would be doubling the frequency of surveillance visits to slaughterhouses, so that each would be visited once a month. He recommended that Mr Hogg write to the Chief Executive of the MHS to instruct him formally, in accordance with procedures set out in the Agency's Framework Document, that appropriate steps should be taken to ensure that the MHS staff enforce the SBO Regulations properly. ¹⁰⁶

6.155 On 30 October 1995 Mr Hogg, Mr Antony Baldry (the Minister of State, MAFF), ¹⁰⁷ Mrs Browning, Mr Carden, Mr Haddon, Mr K Taylor, Dr Cawthorne, Mr Eddy and senior officials of MAFF held a meeting on BSE. Mr Strang minuted Dr Render about the meeting, describing a wide-ranging discussion which included 'the origin of BSE' and the 'increase in CJD cases, and in cases in unusually young people'. Mr Packer described:

. . . the potentially very serious matter of cases where SBO matter - in particular spinal cords - had not been properly removed from carcases. We had to take and be seen to take all necessary action to put this right. He recommended that the Minister should call in the Chief Executive of the Meat Hygiene Service to stress that he attached the highest importance to strict enforcement of our provisions. The Minister agreed. ¹⁰⁸

6.156 Mr Hogg also 'agreed that the MHS should launch prosecutions where that was appropriate . . . [and] that he should call in, as a group, the key organisations, telling them clearly that the results of our inspections in September showed that they were not doing well enough . . . '

6.157 The Minister and Mrs Browning both expressed concerns about reports of CJD among farm workers. Mrs Browning 'stressed the need to continue with our precautionary approach' and added that 'we should not be too dismissive . . . of the possible link between farming and CJD.' The cases of CJD in farmers are discussed in vol. 8: Variant CJD. On public presentation 'the Minister said that he would make plain that the September results of the surveillance exercise to monitor compliance showed that things were not as they should be'. ¹⁰⁹

6.158 The next day Mr Meldrum submitted a revised draft letter of instruction to Mr Hogg, recommending that the Minister should use it as the agenda for the planned meeting with Mr McNeill, the Chief Executive of the MHS. ¹¹⁰

6.159 On 6 November 1995 Mr Hogg, Mrs Browning, Mr Packer, Mr Carden and Mr Osborne met Mr McNeill. The note of the meeting recorded:

The Minister stressed the importance of our controls on SBOs in our strategy for the control and eradication of BSE. He was very concerned about the results of the most recent SVS audit of SBO handling in slaughterhouses. Clearly there had been a number of failings. We had to consider together how to make the slaughterhouses do better.

Mr McNeill shared the Minister's concerns . . . Immediately after this meeting, he would issue instructions to MHS staff stressing the importance of 100% compliance. ¹¹¹

6.160 The note of the meeting recorded that the Minister made