The Public Inquiry into the September 2005 Outbreak of E.coli O157 in South Wales has just been published. It was the largest outbreak caused by E.coli O157 in Wales.
157 cases were identified, with 118 confirmed microbiologically and 109 were of a strain unique to the outbreak. One person, Mason Jones, aged 5 died and 31 people were admitted to hospital. 44 schools were affected – they had been supplied with meat from John Tudor and Son.
The strains of E.coli O157 found in infected people were indistinguishable from those found on cooked meats and raw meats from John Tudor and Son and from samples of cattle faeces taken from a farm.
The report states that the outbreak occurred because of hygiene failures at John Tudor’s premises. Willam Tudor has been prosecuted for these hygiene offences and was sentenced to twelve months imprisonment (according to Wales on-line he served only three months).
The businesses HACCP was “inaccurate and misleading” and William Tudor had lied to EHOs. Disturbingly, the report concludes that the deficiencies had been there for a long time before.
Criticisms were also made of the previous EHO inspections, which the report concedes were made more difficult by the dishonesty of Willam Tudor. However, they are criticised for not assessing the business’ management of food safety and HACCP as well as they could, or should have done.
The school meals contract award system was reported to be “seriously flawed in relation to food safety”. This is extremely worrying: with foods such as cooked meat, if hygiene is not assessed adequately by purchasers through the supply chain management, then there is an immediate failing of that supply chain’s HACCP – no later stage will improve the situation – in fact it will only get worse. The old adage “rubbish in, rubbish out” is only too poignant in these circumstances. Just add a bit of temperature abuse to the scenario and you have E.coli O157, which we already know is infective in very low doses, multiplying in cooked meat and potentially spreading to other foods via food handlers who are unaware that they are preparing a time bomb. They wouldn’t know that they should wash their hands AFTER handling cooked meat – so could easily spread the organism to other foods.
It is astonishing how such a large procurement organisation did not taking adequate care to select their high risk foods. Financial considerations may be important – but it is essential to get expert opinion on the safety of such foods. Third party inspection schemes such as the British Retail Consortium (BRC) help to provide assurance that companies meet high standards, but even then care needs to be taken to ensure that the certification is actually for the premises where the food is manufactured – and not a subsidiary.
For our clients, we offer a food safety supply chain management system which utilises the BRC system, but which also takes into consideration other factors and offers an additional audit should this be necessary. By monitoring complaints (another issue that was deemed inadequate in the Public Inquiry) it is possible to be alerted to problems and go and investigate. Furthermore, by having supply specifications on our data base, we can help clients remove defective products rapidly if there is a recall or alert.
The Report recommends that businesses contracting for the supply of high-risk foods, (the report includes in this definition raw meat as well as cooked), to public sector organisations must be subject to independent food hygiene audits – I would go a step further and require that all procurement companies must seek expert advice to assist with the tender processes: hygiene needs to be high on the agenda at an early stage.
The report puts some blame on poor Abattoir standards and mentions that whilst not an issue in this outbreak, schools need to ensure that adequate facilities are available for children to wash their hands (there is a recommendation that there should be audits to assess this – I think monitoring would be sufficient and practical). Please also refer to a previous Blog item about hand washing in schools and contact us if you would like a free lesson plan or details of our UV hand washing training kit.
