2005 South Wales E. Coli O157 Outbreak - Public Inquiry

Public Inquiry

The Public Inquiry into the outbreak was led by Professor Hugh Pennington, who had also presided over the Inquiry into the Lanarkshire outbreak in 1996. The report was published on 19 March 2009.

The Public Inquiry included more than 45,000 pages of evidence, 258 statements from 191 witnesses, and 63 witnesses were called to the hearing. It cost £2.3 million. William Tudor didn’t cooperate with the inquiry, though was not compelled to do so.

The report made 24 recommendations, 15 relating to food hygiene inspections; some of these were aimed at strengthening key HACCP (Hazard Analysis Critical Control Points) principals and for the Food Standards Agency to review its guidance. It also recommended a substantial review of food hygiene by local authorities in five years (thus 2014).

The report contained criticisms of several local administrations and food hygiene inspection procedures. Bridgend County Borough Council was ultimately responsible for the inspection of John Tudor & Son. Criticism was also levelled at Rhondda Cynon Taf, Bridgend, Caerphilly and Merthyr Tydfil County Borough Councils who had awarded the schools contracts to John Tudor & Sons, calling the process by which the contracts were awarded as “seriously flawed”. Criticism was also levelled at the Meat Hygiene Service which had failed to enforce Meat Hygiene Regulations at the JE Tudor & Sons abattoir.

There was also criticism of the communication procedures of the out-of-hours healthcare service.

The Outbreak Control Team was praised for controlling the outbreak, identifying the source and removing cooked meats from the food chain.

At the press conference at the publication of the Inquiry Report:

E.coli O157 is a particularly nasty organism but it can be prevented from causing infection. It has not gone away; it remains a potential threat to people’s health. There are no specific treatments available to prevent the onset of complications which are often severe and sometimes fatal. Prevention is paramount. Steps must be taken at points throughout the food chain to prevent contamination and cross-contamination, particularly in abattoirs and butchers’ premises that handle raw and cooked meats. The report has reinforced our belief that William Tudor is responsible for Mason’s death. I believe the inspections regimes clearly should be tightened. There is no excuse for the serious failings which occurred, which ultimately led to the E-coli outbreak. I am pleased with Professor Pennington’s recommendations. I am now to go away and digest the report thoroughly. The Professor has studied the evidence that has been gathered during the course of the Inquiry and has returned with very sensible recommendations. We thank him for his time and efforts. Abattoirs’ reliance on self-regulation leads to business owners cutting corners, which is what led to the tragedy such as the E-coli outbreak. I agree that all businesses that are dealing with raw and cooked meats need to have in place an effective and working asset plan.

Professor Pennington has come to the conclusion that William Tudor is to blame for the E-coli outbreak that killed our 5-year-old son and we now look to move on to the Inquest into our son’s death where we hope the coroner will reach an appropriate verdict.

On Mothers Day 2014 I do not want to be standing here sympathising with another family that has lost a child to E-coli O157.”