Volume 6: Human Health, 1989-96
7. Human health developments from January 1996 to 20 March 1996
Discussion
Was Mr Eddy's minute adequate?
Dr Wight's minute
Was Dr Wight's minute adequate?

Was Mr Eddy's minute adequate?

7.98 Mr Eddy's minute set out a chronological account of the discussion at SEAC's meeting. An alternative course would have been to order his minute so as to give prominence to the most significant aspects of the meeting. We do not consider that he is to be criticised for failing to adopt that course; the more so as he made it plain in his minute that he had not attempted to do so.

7.99 We were concerned that Mr Eddy's minute did not record Professor Collinge's concern 'at the occurrence of this number of young cases in such a short period, which could suggest a link in BSE'. Nor did he record expressly that this was the nature of Dr Will's concern. We consider, however, that the detailed account given by Mr Eddy made it plain that Dr Will's concern arose from the occurrence of four definite and one possible case of CJD in young persons, whereas there had been no such sporadic cases in the period 1970-89. It was implicit that the reason for Dr Will's concern was the possibility of a link between BSE and these cases of CJD. It is unfortunate that Mr Eddy failed to add that Dr Will's concern was shared by Professor Collinge, but he could not be expected to provide a verbatim note of everything said at the meeting. As head of the CJDSU, Dr Will's comments were the most important ones to note. We consider that Mr Eddy's minute adequately complied with Mr Meldrum's request to be informed of what transpired at SEAC's meeting.

Dr Wight's minute

7.100 On 9 January 1996, Dr Wight (DH) minuted Dr Harvey (Private Secretary to Sir Kenneth Calman) about the 5 January SEAC meeting. ¹ In respect of the CJD update the minute stated:

There have been 5 definite and one possible case of CJD in individuals aged 30 years or under in the last 4 years (though two of these may be genetic cases). Although this is a significant increase over the incidence in the UK in this age group during the preceding surveillance period, it is not without precedent worldwide. The Committee will be provided with a more definitive statistical analysis, from Professor Smith, at its next meeting. ²

Was Dr Wight's minute adequate?

7.101 Dr Wight had inherited Dr Hilary Pickles's role as the professional with lead responsibility in relation to BSE. She attended SEAC meetings as DH observer. In that capacity, she saw it as part of her role to minute her superiors in order to inform them of any matters arising at the meetings relevant to public health and that the Department needed to take forward. We consider that it was part of Dr Wight's duties to see that her superiors were informed of any matters arising at a SEAC meeting that they could reasonably be expected to wish to know about.

7.102 DH had set up the CJD Surveillance Unit in order to guard against the remote risk that BSE might prove to be transmissible to humans. The incidence of five possible cases of sporadic CJD in persons under 30 when there had been none in the period 1970-89 in the UK, coupled with the fact that Dr Will and Professor Collinge found this worrying, were important facts because of their potential implications for public health.

7.103 The manner in which Dr Wight reported this part of the SEAC meeting was not adequate. Her minute neither suggested that the figures were cause for concern nor disclosed that the head of the CJD Surveillance Unit considered them cause for concern. The cluster of young cases observed within such a short period were without precedent in the world, let alone in a single country, and there had been no such sporadic cases in the UK in the previous surveillance period. Dr Wight's statement that 'it is not without precedent worldwide' was misleading and encouraged false reassurance. When giving evidence she commented that her statement had been 'not quite correct'. She had meant to say that cases in young persons were not without precedent worldwide. She added: 'I probably dashed this off too quickly.' ³

7.104 We are inclined to think that the inadequacy of Dr Wight's minute reflects a failure on her part to appreciate the significance of the statement made by Dr Will that he found it worrying that all the cases in the under-30 age bracket had occurred over a very short period. She told us that she thought it was more appropriate to concentrate on the outcomes of SEAC's discussion, not the contributions of individual members. She saw all contributions made by members as equally valid:

Dr Will was always party to the discussions, and I never thought generally it was worth recording his comments over and above anybody else's. ⁴

7.105 We consider that this attitude showed an extraordinary lack of judgement if applied to comments made by Dr Will on the results of his Unit's surveillance operations. Dr Wight should have communicated the concerns expressed at the SEAC meeting by Dr Will. Had she done so, her unfortunate comment suggesting the existence of precedent worldwide might have been avoided.

7.106 Dr Wight commented on her minute describing the meeting:

One of the main actions that came out of that January meeting, as you will see, was the need for research. And I can remember spending quite a lot of time trying to sort out what we were going to do in terms of developing a good mouse bioassay. That seemed to me a key concern at the time. ⁵

7.107 Research was no doubt important, but of greater potential importance were the possible implications of the results of the CJD Surveillance Unit's findings.