The head of an inquiry into a Welsh
E.coli outbreak which left one boy dead and over 150 other people ill says
more resources must go into food safety.
Inquiry chairman Prof Hugh Pennington
urged food producers to "get to grips" with safety management.
Sharon Mills, whose son Mason Jones,
five, died, said she would campaign to increase sentences over food
In an emotional statement, she said the
butcher to blame served only 12 weeks, although he was jailed for a year.
Bridgend butcher William Tudor was
jailed after admitting supplying contaminated meat to schools across south
Wales in 2005. Mason, from Deri, Caerphilly county, died after contracting
the bug's 0157 strain in 2005.
Ms Mills said the report
recommendations "need to be implemented immediately as this is the
only way to ensure that public safety is protected".
She added: "The report shows that
butcher William Tudor was to blame for the outbreak but also that public
authorities needed to do more to protect us all.
"My son would be alive today if
proper systems had been put in place in 2005 to avoid cross-contamination
in food processing and the systems need to be put in place as soon as
possible so no-one has to go through such a tragedy again."
Prof Hugh Pennington has called for better implementation of
food hygiene procedures
First Minister Rhodri Morgan said the
Welsh Assembly Government, which commissioned the inquiry, would work with
enforcement agencies to ensure the public's safety.
Even though the risk of another
outbreak could not be wholly eliminated, he said he hoped to minimise the
chances of it happening again.
Forty-four schools across the south
Wales valleys were affected in the outbreak and 156 people were made ill.
It was the largest outbreak of its kind
in Wales, the second biggest in the UK and the sixth largest worldwide.
Prof Pennington, a microbiologist who
also investigated an E.coli outbreak in Lanarkshire in 1996, chaired the
inquiry into the south Wales outbreak.
Twenty-one elderly people died in the
Lanarkshire outbreak after eating contaminated meat from a Wishaw butcher.
Photos shown during the inquiry into
the south Wales outbreak, which finished last May, revealed unhygienic
conditions at the butcher's premises, with congealed blood on machines and
pieces of raw meat left on the floor.
Prof Pennington said the outbreak was
"particularly shocking" because the systems regulating food
safety at the time had been reformed as a result of the 1996 outbreak.
He said the only systems which did
their job in the outbreak were in control and clinical, and there had been
failures everywhere else.
"We owe it to the memory of Mason
Jones to learn the lessons from this outbreak and to remember them,"
said Prof Pennington.
He made 24 recommendations in his
report but said the requirements for food hygiene in place at the time of
the outbreak should have been sufficient to prevent it.
His report found there were serious and
repeated breaches of food safety regulations at Tudor's premises, and that
the butcher had "falsified certain records that were an important part
of food safety practice".
The inquiry heard that Tudor
"misled and lied to" environmental health inspectors and that
"deficiencies had been there for a long time before".
Prof Pennington also criticised
inspectors from Bridgend council for not assessing or monitoring the firm's
management of food safety "as well as they could or should have
The fundamental flaws in John Tudor and
Sons' hazard analysis critical control point (HACCP) plan, which delivers
food safety, were also missed, he said.
The process by which meat supply
contracts were awarded to John Tudor and Son in 1998 and 2002 by Rhondda
Cynon Taf, Bridgend, Caerphilly and Merthyr Tydfil councils were
"seriously flawed", said the report.
"If anything was likely to have
encouraged William Tudor to get his act together on food hygiene, it would
have been the direct threat of failing to secure, or losing, what was a
very significant contract," said Prof Pennington.
He also criticised the Meat Hygiene
Service for allowing JE Tudor & Sons abattoir, which supplied meat to
John Tudor & Son, to continue functioning in breach of legislative
However Prof Pennington did praise the
work of the outbreak control team, saying they reacted quickly to remove
cooked meats from the food chain.
He said: "But for the quality of
the analysis and control measures, the outbreak would have been
considerably more severe and prolonged."
Prof Pennington recommended that
resources be made available to ensure businesses got to grips with food
He also said the Food Standards Agency
should review its current guidance. In terms of food safety inspections,
officers who check HACCP plans and their overseers should get more
training, said Prof Pennington.
Procedures to log issues and concerns
about firms' food safety should become common practice for these officers,
He also called for all inspections to
be unannounced unless there were circumstances where a visit had to be
All local authorities in Wales should
review their policies, procedures and systems against the issues identified
in the report, he said.