Report on the circumstances leading to the 1996 outbreak of infection with E.coli 0157 in Central Scotland, the implications for food safety and the lessons to be learned.

Chapter 1 Introduction

The Pennington Group

1.1 As part of the Government response to what appeared to be emerging as a serious outbreak of infection with E.coli O157 in Central Scotland, the Secretary of State for Scotland announced in Parliament on 28 November 1996 the establishment of an Expert Group, under the Chairmanship of Professor Hugh Pennington, with a remit "to examine the circumstances which led to the outbreak in the central belt of Scotland and to advise [him] on the implications for food safety and the general lessons to be learned". We were asked to examine the present knowledge of E.coli taking into account scientific research in this area, and the adequacy of present arrangements for, and guidance on, handling food poisoning outbreaks. The Secretary of State asked us to let him have any priority recommendations we wished to make by the end of 1996.

1.2 While our study was underway, a further outbreak of infection with E.coli O157 occurred in a nursing home in Tayside. On 7 February 1997, the Secretary of State for Scotland asked us to take account of the Tayside outbreak in our deliberations and the production of this report. We were also kept informed of outbreaks which occurred in the Borders and Lothian in February 1997 and of other significant cases of infection that occurred during our enquiry.

1.3 The Pennington Group convened from the beginning of December 1996 until the end of March 1997. We met key individuals involved in the management and control of the Central Scotland outbreak, the Tayside outbreak and also recent past outbreaks of infection with E.coli O157 in Scotland; and we gathered advice and information from a wide range of sources to aid our deliberations. Membership of the Group, along with details of the central Government officials who directly advised and assisted with our work, is set out in Annex I.

1.4 During our study we inevitably touched on matters in which Group members have, or had, personal or professional interests or involvement. In line with normal practice, declarations of interest were made at the commencement of our study and at appropriate stages throughout our deliberations.

Interim Report and Priority Recommendations

1.5 Our interim report and priority recommendations were submitted to the Secretary of State on 31 December 1996 and on 15 January 19971 in the House of Commons he made a statement on the report setting out his response to it. The summary of recommendations from the interim report is reproduced at Annex II; and the Secretary of State's statement at Annex III.

1.6 This final report incorporates, in appropriate sections, our interim findings and priority recommendations - amended and/or clarified and developed in the light of further Group deliberation and evidence or representations received since submission of our interim report.

Fatal Accident Inquiry/Criminal Proceedings

1.7 On 5 December 1996, the Crown Office announced that a Fatal Accident Inquiry (FAI) would be held into the deaths arising from the outbreak of infection with E.coli O157 in North Lanarkshire. On 10 January 1997, Mr John Barr of J. Barr and Sons, Butchers of Wishaw was charged with culpable and reckless conduct arising from the alleged supply of cooked meats in relation to a function at the Cascade Public House in Wishaw. The criminal trial has yet to take place. In line with normal practice, the FAI will not commence until the completion of any criminal proceedings.

1.8 It will be for the FAI and any criminal proceedings to examine the roles of individuals and their actions during the course of the Central Scotland outbreak. In approaching our work, therefore, we sought to concentrate on the broader issues and lessons to be learned from the Central Scotland outbreak, the Tayside outbreak and the other outbreaks which we examined. Care has been taken, in compiling this report, to avoid discussion of issues which may be prejudicial to the FAI or any criminal (or civil) proceedings or which may, contrary to the public interest, delay publication of this report. We have, nonetheless, taken full account of all the evidence offered and information we have gathered, including on the Central Scotland outbreak, in reaching our conclusions and recommendations.

The Approach to This Report

1.9 In approaching our task, we were committed to identifying measures which would help reduce the possibility of future infection with E.coli O157 generally and, in particular, further outbreaks of the scale involved in Central Scotland. We were also determined, in considering food safety legislation, guidance and practices that, in coming to our views, public health considerations should be regarded as paramount in the handling of potential and actual outbreaks of food poisoning.

1.10 We were persuaded of the over-riding need to tackle the dangers which E.coli O157 presents and to reinforce public health considerations in the area of food safety. It is this overarching principle that has guided our work. Moreover, while we believe that the measures we propose can be justified with reference to the circumstances of the outbreaks we have examined, we readily acknowledge the influence of more general concerns about the growing incidence of food poisoning cases, and their economic and social costs, in supporting the precautionary and preventive approach we have adopted. We believe the recommendations we make will have an effect in helping to reduce the incidence of infection not only with E.coli O157, but also with other potentially harmful foodborne organisms. Nonetheless we were also aware throughout of the practical and financial implications, for businesses and others, of any proposed changes. These were taken fully into account.

1.11 We also applied in our deliberations the principles of the Hazard Analysis Critical Control Points (HACCP) system2. We sought to identify the critical points in the process of food production "from farm to fork" at which, based on our examination of the circumstances of recent outbreaks, there seems to be most risk of contamination (with E.coli O157 in particular); and we have recommended a range of complementary measures to be put in place in the short term to help reduce that risk pending full implementation of the HACCP system by industry. We have also made recommendations for research and about the underlying systems and practices needed to identify, manage and control outbreaks of foodborne disease. The structure of this report reflects that approach.

Acknowledgements

1.12 We were assisted in our work by helpful and constructive advice and assistance from many people and organisations. A list of acknowledgements of those from whom the Group sought advice or information is included at Annex IV. Any omissions are purely accidental. We were particularly grateful for the documents provided by the Meat and Livestock Commission (MLC), the Meat Hygiene Service (MHS), the Advisory Committee on the Microbiological Safety of Food (ACMSF) and for the literature review on E.coli O157 carried out by Dr David Jenkinson. Copies of these documents, and of any of the other written evidence provided by those listed in Annex IV that was not submitted on a confidential basis, is available on request3.

1.13 A large number of comments or representations were also received either in response to consultations undertaken on issues raised in the interim report or unsolicited. Our thanks are due to all those who contributed, whether on request or voluntarily, towards our deliberations, the production of this report and the recommendations it contains.

1.14 Our grateful thanks are also due to the Secretariat to the Group without whom our work could not have been completed, and this report would not have been produced, within the ambitious timetable agreed. We are particularly grateful for the unstinting efforts of our Secretary, Robin Weatherston whose meticulous planning of our work and clear and comprehensive minuting of our deliberations and drafting of this report was of an extremely high order.

Cost of the Study

1.15 Up to the time of producing this report, the cost of the Group's work has been ý45,000 representing the full direct and indirect costs of the Secretariat and the travelling and subsistence costs of Group members.

1 See Official Report, columns 323-338.

2 See Chapter 4.

3 SOAEFD: Tel: 0131-244 6185.