Five-year-old Mason Jones died a painful and unnecessary death.

Mason (right) died Oct. 4, 2005, from E. coli O157 as part of an outbreak which sickened 161 — primarily schoolchildren — in south Wales.

Mason’s mother, Sharon Mills, said in 2005 that her son’s death was "avoidable" and that lessons "have to be learnt."

"There was nothing wrong with him, only that he ate a dinner – an innocent child eating a dinner. I never thought you could die from E. coli. Never. I had heard of E.coli and I just thought it was food poisoning. I never ever thought Mason would die from it."

Today, Professor Hugh Pennington concluded that serious failings at every step in the food chain allowed rogue butcher William Tudor to start the 2005 E.coli O157 outbreak, and that while the responsibility for the outbreak, “falls squarely on the shoulders of Tudor,” there was no shortage of errors, including:

• local health types did not sufficiently assess or monitor John Tudor & Son’s food safety management or HACCP plan;

• the abattoir was allowed to continue slaughtering despite longstanding and repetitive failures, in breach of legislative requirements and without significant improvements; and,

• the procurement process was “seriously flawed in relation to food safety”

Prof Pennington said he was disappointed that the recommendations he made more than 10 years ago, following the E.coli O157 outbreak in Wishaw, Scotland, which killed 17 people had failed to prevent the South Wales Valleys outbreak.

“I was very disappointed that the more we looked into what happened in South Wales, the greater the number of parallels between Scotland and Wales. That was disappointing for me personally because I had spent a lot of time coming up with the recommendations in 1996 and 1997 – they were implemented but somewhere things fell down in the way they were implemented. I am looking for these recommendations to be implemented as soon as possible because E.coli is as powerful a threat now as it was in 2005.”