Volume 9: Wales, Scotland and Northern Ireland
Part 2: Scotland
10. Chronological account of specific Scottish issues
Communication with the CMO for Scotland
vCJD

10.61 By 1995 Dr Robert Kendell had been CMO for Scotland for four years. ¹ He was a psychiatrist by training and told the Inquiry that he had little prior knowledge of public health issues. ² He relied heavily on Mr Scudamore (the ACVO) for advice on all animal health issues. ³ He told the Inquiry that, at that time, he was unaware that BSE had been transmitted to a pig in 1990. He knew that a similar spongiform encephalopathy had been reported in several domestic cats, and in a zoo puma, but he did not know the scale of the feline epidemic. ⁴ He was aware that the majority opinion of the time was that BSE had indeed crossed the species barrier. ⁵

10.62 During 1995 there was increasing general concern about the possibility of a link between BSE and CJD. The occurrence of CJD in humans was discussed in a number of SEAC meetings throughout that year. Dr Kendell, however, said in oral evidence that he never received copies of SEAC minutes during his term as CMO. ⁶ Moreover, 'no Scottish Office official attended meetings of SEAC, nor were the Committee's minutes sent to the Scottish Office until April 1996'. ⁷ Dr Kendell had assumed at the time that any important information emanating from SEAC would have reached him via Dr Ailsa Wight, DH 'observer' of SEAC, who was in close contact with Dr Rosalind Skinner, an SMO in the Scottish Office. ⁸ Dr Skinner said that she never encountered problems in obtaining information from the SEAC meetings. Indeed, she told the Inquiry that in her view the Scottish Office's lack of representation on the Committee did not hamper them in any way because they could 'readily' turn to Dr Robert Will of the CJDSU to discuss issues that came up at SEAC.

10.63 Dr Kendell also received information directly from Dr Calman, who was the DH CMO from 1991 to 1998 and had previously been CMO for Scotland. ⁹ Dr Kendell said that his Department did not make an issue out of the failure to receive the SEAC minutes because the method of obtaining information in the way described above was 'fairly standard'. He went on to explain that:

Whitehall Departments are often reluctant to give territorial Departments their documents and on many issues we have to rely on - it is really relying on a good personal relationship between somebody in the Whitehall Department . . .

This system usually worked 'fairly well', but Dr Kendell thought, with hindsight, that it would have been 'enormously helpful' for him to have seen the SEAC minutes at the time he was CMO. ¹⁰

10.64 Mr William Gardner, Veterinary Head of Section (Scotland), told the Inquiry that the vets in Scotland did not receive full sets of SEAC papers until after 1997, when MAFF and DH decided that SEAC should report to Ministers in England, Scotland and Wales. ¹¹ However, Mr Gardner said that he and his colleagues 'always heard through one channel or another the substance of SEAC deliberations'.

10.65 Mr Scudamore said that he did not recall seeing SEAC papers except when he asked for specific items. In those instances he was not necessarily provided with documents that had been placed before the Committee, but often just with summaries of specific experiments. He also asked for and received updates about the Committee's work from time to time. ¹²

10.66 On the administrative side, Mr Davison could not recall having received any SEAC minutes, but his successor, Dr Matheson (1994-96), told the Inquiry that these were sent to his Head of Branch (Mr N Kernohan and, from May 1995, Mr J Symington), who passed them to him. Because the papers were bulky and technical, he merely scanned them briefly and sent them to be filed. He recalled that Mr Symington had at one stage requested that a more formal system of sending the papers be instituted, and that they had arrived with more regularity after that. ¹³

vCJD

10.67 Although the CJD Surveillance Unit in Edinburgh (see paragraphs 9.28-9.29), was partly funded by the Scottish Office, it did not report directly to it. Dr Will, Director of the Unit, told the Inquiry that:

. . . the arrangements of reporting with the Department of Health have always been fairly clear to me and [what I] agreed with the Department of Health is that I will report to London and any information will then be disseminated to the territorial Departments. And that is still the case now. ¹⁴

10.68 Despite this Dr Kendell said that he was in close contact with Dr Will during 1995, and that they often discussed CJD. Dr Kendell had also kept fully up to date with the figures produced by the CJDSU showing the annual incidence of the disease. However, he said in evidence that up until mid-1995 he had thought it unlikely that there was a link between BSE and CJD.

10.69 During August 1995 Dr Kendell's thinking began to change. He read the CJDSU's fourth annual report two months before its publication. ¹⁵ The CJDSU's findings suggested clearly to him that 'the epidemiology of CJD was changing' (with a noteworthy incidence in young people and in farmers), and that 'potentially alarming things were happening but there were plausible explanations for all of them'. ¹⁶ Working on the assumption that the bovine brain and first two segments of the spinal cord were the infective organs of the greatest concern, he was unable to see how farmers might contract the disease when they were not in contact with these parts of the animal. ¹⁷ More importantly, although the number of farmers affected was high, it was not out of line with countries which were free of BSE, so it was probably chance. ¹⁸ He was also reassured by the fact that some eight other cases of CJD in teenagers had been reported from other countries which did not have BSE, and that the original case description of the disease in the 1920s had been in a 23-year-old. ¹⁹ In addition, the pathology of one of the new cases was said by Dr Will to be unusual. ²⁰

10.70 Following the report's publication and news of a case of CJD in a farmer who had had a case of BSE in his suckler herd, SEAC saw no reason to alter its advice on the precautions necessary to protect either public health (including that of farmers) or animal health. They issued a statement to this effect on 23 October 1995. ²¹

10.71 On 25 October Dr Kendell and Dr Calman attended a meeting with the Permanent Secretary of MAFF, Mr Richard Packer, at which they were told that there had been four or five instances when spinal cord had been found still attached to carcasses after processing. They subsequently learned that the correct incidence was four or five cases per 1,000 carcasses. Dr Kendell said in oral evidence that his ignorance of the correct incidence, together with his lack of access to SEAC minutes, and hence to the new knowledge of the infectivity of the spinal cord, had coloured his thinking about the safety of beef. ²² As it was, he was satisfied with Dr Calman's course of action, which was to seek assurances from the MAFF Minister, at that time Mr Douglas Hogg, that the situation would be remedied. ²³

10.72 A month later MAFF issued a news release to the effect that SEAC had 'expressed grave concern about the findings by the State Veterinary Service of a number of instances in which slaughterhouses had left small pieces of spinal cord attached to carcasses after dressing'. However, SEAC had 'reiterated its advice that beef was a safe and wholesome product'. The news release also quoted Dr Calman, who said:

There is currently no scientific evidence that BSE can be transmitted to humans or that eating beef causes CJD. ²⁴

10.73 In response to reports that Scottish schools had been advised by the Local Authorities Caterers' Association to take beef and beef products off their lunch menus, and also to comments made by Sir Bernard Tomlinson in the media, ²⁵ Dr Kendell issued a statement on 7 December 1995:

The Government's independent scientific advisers are saying consistently that there is no evidence at all that eating beef or other foods derived from beef is dangerous. My general advice to people is therefore to carry on eating what you want to eat as you were before.

We have no evidence of any connection between BSE and CJD. However, both conditions are being closely monitored and studied by scientists, in this country and abroad, as there is much about both that is still unknown. ²⁶

10.74 Dr Kendell told the Inquiry that he strongly suspected that he made the statement at the request of the Scottish Office press office. ²⁷ However, he did not discuss the wording of his statement with the Secretary of State for Scotland, now Mr Michael Forsyth, or any other Minister before it was issued. ²⁸ He said in oral evidence that he did not feel that informing anyone was necessary as, in his view, what he was saying was 'entirely in line' with what other people were saying. ²⁹ Only after the statement was made did he send a minute to Scottish Office Ministers to inform them of his action. After quoting his public statement, he said:

The core of the dilemma is there is no evidence of any connection between BSE and CJD, but on the other hand neither I nor anyone else can give a cast iron guarantee that eating beef or beef products from UK farms does not carry any risk of transmitting the causal agent of CJD, a disease which is invariably fatal. Worse still, this uncertainty may last for 10 years or more. ³⁰

10.75 Dr Kendell told the Inquiry that:

The statement reflected my own opinion, based on my assessment of the information available to me at that time, and I would not have been prepared to make any statement that was not based on my honest opinion. It was intended to reassure the people of Scotland that, despite the things they might have read or heard, there was no good reason for them to alter their eating habits, while at the same time making it clear that I was not in a position to give a categorical assurance that 'beef was safe to eat'. ³¹

10.76 However, Dr Kendell said that with hindsight he might have omitted the words 'at all' from the text of his statement, making it less emphatic. ³²

10.77 On 18 March 1996 Dr Kendell advised Scottish Ministers of the evidence of a new form of CJD, discussed at the SEAC emergency meeting two days earlier. In particular, he cautioned that if a new disease had emerged, a link with BSE should be suspected. ³³

10.78 Dr Kendell attended the subsequent SEAC meetings on 19, 23 and 24 March. He issued a public statement on 20 March immediately after the announcement of SEAC's latest advice in Parliament. His statement reported that SEAC had concluded that the series of 10 cases of CJD in young people reported to the CJDSU in the past two years were most likely to be linked to exposure to BSE before the introduction of the SBO ban. He noted that SEAC had recommended a number of further controls 'designed to reduce still further the risk of BSE spreading to people' and that the Government had accepted these recommendations. He continued:

Against this background I would like to emphasise the following:

Although CJD is fatal and incurable it is very rare. (There were 55 cases in the whole of the UK in 1994 and only 40 in 1995.) It is also no commoner in the UK than in other countries whose cattle are free of BSE.

There remains no scientific evidence that beef itself (as opposed to the specific list of bovine offals) is not safe to eat, and the various controls that have been implemented since 1989 have reduced any possible risk still further. ³⁴