This barfblogging stuff can be fairly cool (thanks, Bill).

I wrote an opinion piece about the on-going inquiry into the 2005 E. coli O157 outbreak in Wales, and how the findings to date were somewhat similar to what happened after the 1996 E. coli outbreak in Scotland.

Didn’t send it to any media outlets, but posted it on barfblog.com.

That was Feb. 27, 2008. Yesterday, the opinion piece/blog entry apparently made an appearance at the inquiry in Wales.

The Western Mail reported that the Welsh E. coli public inquiry was yesterday shown a blog entry suggesting that chairman Professor Hugh Pennington was trapped in Groundhog Day and that worrying parallels have emerged between the world’s worst E.coli O157 outbreak and the cause of the South Wales Valleys outbreak.

The Scottish outbreak was caused by meat produced by award-winning butcher John Barr, who was found to be using the same knives to handle both raw and cooked meat.

The inquiry into the South Wales outbreak has heard how butcher William Tudor relied on one vacuum-packing machine for both raw and cooked meats. The single machine, which was in use for at least nine months before the outbreak and has been repeatedly referred to as a serious risk of cross-contamination.

In 1999 Prof Pennington said,

“The prospect of another Mr Barr type situation is still quite real because everybody I talk to in meat inspection and environmental health tells me there are people who are still not doing the right thing.”

But despite the recommendations, Tudor repeatedly passed routine environmental health inspections and was awarded his butcher’s licence just over a month before the outbreak, which killed five-year-old Deri Primary School pupil Mason Jones (right), even though Bridgend Council’s inspectors were aware that he was working with only one vac-packing machine.

Asked about the Groundhog Day blog, Dr Salmon said,

“The butcher, John Barr, as far as I understand, was extremely well connected in the location of which his enforcement was taking place. It will be important to take into account how much such considerations may or may not have applied in the case of William Tudor.”

Sharon Mills, 33, whose five-year-old son Mason Jones died in 2005 after contracting E. coli O157, told the public inquiry in Wales today that she was devastated when she learned he had the bug.

In her statement to the inquiry, Ms Mills said,

"When Mason was hallucinating he said to me, ‘Mamma, I’m dying.’ Mason had never been a child who had ever talked about death – his words therefore hit me for six. You could see it in Mason’s eyes that when he said these words he meant what he was saying. That was the first time that I began to form a deep-rooted feeling that Mason could die. I tried to reassure him and talked about things like how many children he was going to have when he got older. I told him that the doctors and nurses were going to make him better. This night was the worst of my life. …

"He was a beautiful child and I couldn’t understand why this had happened. When Mason passed away I felt numb. I felt as if I were looking at someone else’s child. I thought that it couldn’t be Mason lying there. It was unreal. I felt that I was having a nightmare and that I couldn’t wake up. I have felt like that ever since. Returning home without Mason felt as if my life had ended."

Professor Hugh Pennington has become unstuck in time.

More like Bill Murray in Groundhog Day, than Billy Pilgrim.

In November 1996, over 400 fell ill and 21 were killed in Scotland by E. coli O157:H7 found in deli meats produced by family butchers John Barr & Son. The Butcher of Scotland, who had been in business for 28 years and who was previously awarded the title of Scottish Butcher of the Year, was using the same knives to handle raw and cooked meat. That’s a food safety no-no.

In a 1997 inquiry, Prof. Pennington recommended, among other things, the physical separation, within premises and butcher shops, of raw and cooked meat products using separate counters, equipment and staff.

In the past two weeks, Prof. Pennington has heard in a new inquiry how John Tudor and Son, the Butcher of Wales, used the same machine to vacuum package both raw and cooked meats, leading to an E. coli O157:H7 outbreak beginning in Sept. 2005, which sickened some150 children in 44 schools in southern Wales and killed five-year-old Mason Jones.

How can the good professor awaken from this recurring national nightmare?

The inquiry into the 2005 outbreak, which began in Feb. 2008, is again chaired by Prof. Pennington and has again heard testimony highlighting gross managerial failures and shocking levels of complacency.

So far, the Butcher of Wales has been shown to have:

• encouraged staff suffering from stomach bugs and diarrhea to continue preparing meat for school dinners;
• known of cross-contamination between raw and cooked meats, but did nothing to prevent it;
• used the same packing in which raw meat had been delivered to subsequently store cooked product;
• operated a processing facility that contained a filthy meat slicer, cluttered and dirty chopping areas, and meat more than two years out of date piled in a freezer;
• a cleaning schedule at the factory that one expert called "a joke;"
• falsified crucial health and safety documents and lied about receiving hygiene awards; and,
• supplied schools with meat that was green, smelly and undercooked.

Professor Chris Griffith, head of the food research and consultancy unit at the University of Wales Institute, Cardiff, told the inquiry the culture at the premises was “dominated by saving money.”
This would explain why Tudor retained his contract to supply schools: because he was the cheapest.

So who allowed Tudor to operate under such conditions?

Government inspectors.

(This is why I get substantially nervous when any food producer, such as California lettuce and spinach growers, says they meet inspection standards.)

Prof. Pennington has heard that Tudor and Son was visited several times in the months leading up to the Sept. 2005 outbreak, that inspectors knew there was only one vac-pac machine being used for both cooked and raw meats but, despite Pennington’s 1997 recommendation, inspectors decided the business did not pose "an imminent risk" to human health.

A retired senior Food Standards Agency official, who now works as a freelance food safety consultant, told the inquiry that the use of a single vac-pak for both raw and cooked meat was “like playing Russian Roulette."

The official also chided inspectors for failing to note deficiencies in Tudor’s written food safety plan and stated, rather bluntly, "There was a failure in the series of inspections to identify poor hygiene and working practices and a failure to take action."

The inspectors also took on "face value" explanations offered by Tudor and his staff for various food safety failures.

Buyers with the school boards were equally eager to look the other way to save a pound. One supervisor told the inquiry, “You have to have faith in people. You don’t expect them to make up stories about meat.”

Except that inspection and regulatory regimes for meat were created in Southern France in the 12th century precisely because people do make up stories about meat. Europe has almost 1,000 years of regulatory experience with shoddy food suppliers;  that experience was not applied in southern Wales in 2005. As a result, 5-year-old Mason Jones died a painful and unnecessary death. Dozens of kids were hospitalized and will suffer life-long effects.

The official purpose of the inquiry is to provide recommendations designed to prevent a similar outbreak happening again.

As Prof. Pennington knows, that was supposed to happen in 1997.

E. coli butcher William Tudor supplied schools with meat that was green, smelly and undercooked but retained his contract because he was cheap.

The Western Mail reports that even though school cooks raised numerous concerns, Tudor was not seen as a major problem and councils continued to buy their meat from him because he was the supplier that gave the “lowest overall offer.”

The inquiry heard that between 1998 and 2005, school cooks in Merthyr lodged complaints with the authority’s catering department. These included:

Ham – green and gone off;
Roast pork – smelling and falling to bits;
Mould on slices of turkey;
Feather in cooked turkey.

Yummy.

Brian Curtis, a retired senior Food Standards Agency official, who now works as a freelance food safety consultant, told a public inquiry that the use of a single vacuum packing machine for both raw and cooked meat at E. coli butcher William Tudor’s factory was “like playing Russian Roulette." adding,

"It seems to me, in a crude analysis, it is a bit like playing Russian Roulette. You might get away with it the first time, the second time, the third time, but progressively you have a greater chance the gun will go off and what we are talking about is a nine-month period."

The South Wales Echo also reports that Mr Curtis told the inquiry yesterday that a document produced by Tudor — his HACCP plan —  "was not a valid plan. It was not a safe plan,"  but that Bridgend council’s environmental health officers, “failed to identify the deficiencies and weaknesses” of the document.

Mr Curtis also said there had been flaws in the way Tudor’s was inspected because there were too many announced visits that allowed him to prepare and that the inspections themselves had not been undertaken thoroughly, stating,

"There was a failure in the series of inspections to identify poor hygiene and working practices and a failure to take action."

A food safety inspector who visited John Tudor & Son five times in 2005 told the E. coli inquiry in Wales today that although a single vac-pac machine was being used for cooked and raw meat, the business did not pose "an imminent risk" to human health.

Media Wales reported that Angela Coles, a Bridgend Council environmental health officer said she took on "face value" explanations from the company’s manager Celyn Williams about training and how the vacuum-packaging machine would be cleaned between being used for cooked and raw meats.

James Eadie, the inquiry’s lead counsel, also questioned Amy Lewis, a senior environmental health officer at Bridgend Council, about holding temperatures after cooking gammon, which exceeded Tudor’s own HACCP plan, stating,

"Is it inconceivable that you would have asked about temperatures, found out it was non-compliant with a crucial step in the HACCP plan and then made no record or note of it? You didn’t pick this up?"

Ms Lewis replied, "I don’t recall."

The inquiry also heard that E. coli butcher William Tudor was granted his first butcher’s licence despite not possessing a relevant food safety certificate; instead he passed a 26-question test, set by senior Bridgend Council environmental health officers in 2001.

A public inquiry heard Friday about a string of failures by food safety officers responsible for inspections of William Tudor’s meat plant leading up to the September, 2005 E. coli O157:H7 outbreak.

The South Wales Echo reported that Amy Lewis, an environmental health officer, admitted failing to check Tudor’s claims that his staff had food hygiene certificates – but only after a series of questions by lead counsel to the inquiry James Eadie, including the evidence that Tudor himself had admitted the staff were never trained.

A second officer, Ian Sullivan, who was responsible for advising on a critical food handling plan had only been employed for a few months when he became responsible for supervising Tudor and had never dealt with a business of that size.

A third officer, Joanne Evans, admitted mistakes in filling out forms that affected how often the Bridgend Industrial Estate plant was inspected.

Earlier in the week, Tudor said in a letter read out at the Cardiff inquiry, he followed official hazard analysis guidelines, and the practices used by his firm were supervised by Bridgend Council.

It was also revealed that Tudor, who was sentenced to 12 months in jail for his actions, was released after serving on 12 weeks.

The parents of five-year-old Mason Jones (right), who died during the outbreak, were unaware of Tudor’s early release until the start of this week’s public inquiry and called it a “travesty of justice.”

Garyn Price, 12, who almost died after contracting E.coli during the outbreak, was quoted as saying he was “disgusted” Tudor was allowed out of prison so soon and said,

“I got upset when my mum told me he was out. They should’ve kept him in prison longer. I don’t think he will have learned his lesson.”

There were 157 probable cases of the E.coli O157 strain and 118 confirmed during the outbreak, which was declared on 16 September 2005 and declared over on 20 December that year.

It affected 44 schools across south Wales, making it the largest outbreak of its kind in Wales, and the second biggest in the UK.

South Wales Echo is reporting that the factory run by E.coli butcher William Tudor contained a filthy meat slicer, cluttered and dirty chopping areas, and meat more than two years out of date piled in a freezer.

Professor Chris Griffith, head of the food research and consultancy unit at the University of Wales Institute, Cardiff, told the inquiry the culture at the premises was “dominated by saving money.”

His report also included statements from those who worked at the factory, who reported that a cling film machine stored in the toilets was used to wrap faggots in the cooked meat area and that rotting meat and maggots were found in drains.

Staff also said Tudor encouraged them to continue preparing meat for delivery to schools even when they were suffering from sickness and diarrhoea.

Colin Houston, deputy head of the enforcement division of the UK Food Standards Agency told a public inquiry yesterday that  E.coli butcher William Tudor (nice tag line) falsified crucial health and safety documents and even lied about receiving hygiene awards.

The inquiry heard the claims had been made in a document known as a HACCP (Hazard Analysis and Critical Control Point) plan which Tudor, as a butcher, was required by law to prepare and implement to help reduce the risk to the public.

Mr Houston told yesterday’s hearing in Cardiff Bay that another of Tudor’s false claims in his HACCP plan had been to suggest that his factory had completely separate areas for the preparation and handling of raw and cooked meat.

Mr Houston told the inquiry he would have expected environmental health officers to check whether this was in fact the case during inspections of the premises on Bridgend Industrial Estate.

I can’t wait to hear from the inspectors.

The inquiry also heard from a handwriting expert who found Tudor had falsified vital records detailing the temperature meat was stored at and cleaning records.

"There is conclusive evidence, as she (the handwriting expert) put it, that the logs and cleaning standards forms dated July 2004 onwards, were not completed on a daily/weekly basis, but that the batches of entries were made at one time.”