Pennington Report

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When did the outbreak break
2005
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Ecoli?
0157
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Total of how many cases?
157 cases, 44 schools effected, 31 admitted to hospital - mason jones died
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What was the inquiry?
To enquire into the circumstances that led to the outbreak of E.coli 0157 infection in south wales in september 2005 and into the handling of rhe outbreak and to consider implications for the future and make reccomendations accordingly
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What is E.coli 0157?
Ecoli 0157 live harmlessly in digestive systems, but some produce toxns, highly infectious and only few organisms can cause potentila fatal infection. Kidney or brain dmaamge - children under 5 and ove 75 partically volunerable - compliations.
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Soruces of Ecoli 0157
intestines of cattle and cheep, infected animals show no symotoms but shed bacteria, surface on their faeces. Abbatoirs take steps to prevent flesh coming in cobtact with E.ciku 0 cooking action and HACCP.
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What was introduced in 1996
Butchers Licening from E.Coli in scotland
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Source?
Cooked meat and hams contamined, microbiogocial testing and typing - strains of E.Coli - w
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Abattoir called?
J.E Tudor and Sons LTD which supplied meat to John Tudor & Son
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William Tudor punishmenet?
10 years imprisonment
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Who was responsible for inspections of John Tudor & Son?
Bridend Country Borough Council by EHO - clues were missed 0 HACCP
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FSA audit
Bridgend audited in 2008 - 18 months prior to outbreaj - not examined to see techniques of effective inspeciton
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School meals
Contracts into school, contracts in 1998 and 2002 and flawed - lack of roles and complaints
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Meat Hygiene Regulations
should ahve been followed and enfoced - failed to perform its effectively and overall enforcement - "light touch" enforcement was wrong- unsafe were strong were noted by it was allowed to continue into buisness without improvement
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Schools and hygiene?
2004 Wales - toilets and assist schools in aduit, did not contrubute byt provision tajes on importance of spread
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recomendations
Ensure procedures and systems are in place to deal with E.coli, grips of HACCP principles, adiditonal resources made available for HACCP, documented procedures, effective, documented food safety programme, Butchers Licening scheme should ahve guided
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Other recomendations
FSA shoudl review its current guidance and be proactive in generating new guidance where needs are identifies, remove confusion surrounding what solutions should be used to prevent cross-contaim from sufaces and equiptment
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Haccp must be?
Audit based, trainign should be provided, and EHO must have a copy of HACCP in each insepcition, system of logging concerns or potential probelms by "red flagging - all insepctionsbshould be unanouched, employees and discussion with inspecition fpddd
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EHO
Trained in relation to HACCP and HACCP auditing
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E.Coli 0157
Escherichia Coli common bacterium - many times - 10 million bacteria in te gut, need them to synthesise vitamins and metablise food components named after Theodor Escherich - 1885: Called an emerging pathogen because its evolving quickly
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Diagnosis of E.coli and sources?
growing in laboritory- rnage of farm animals and main source is in intestines in cattle and sheep - 9% catte may contain E.coli - bacteria moved towards end of animals gut and in its rectum - factors of shed include, age, stress and probably time of
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Infection of E.Coli?
Is made by gorwoing the bacterium in the labority- culture can be identifies and counted by colour - takes about a day -Sub-typing fingerprinting - sub-testing takes a week - travels to the stomach and then to intestinges - large intetension -
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Infection conc.
Toxin causes imflammority and aborbed and be toxi - damange small blood vessels - bleeding and in the kidnesys - period between infection with the infection and onset is 2-12 days commonly 3 days - mild dirrhoae and sickness - still rare,
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Other outbreaks?
November 1992 and 1993 - outbreak 4 deaths in America burgers , May 2000 Canda, 2,300 fell ill and 163 cases, 4 died
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Casues of E,coli 2005
950 England, and Scotland 166
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Prevention of infections?
Slaughter, HACCP, prevention cross contamination, raw cow milk? , beefburgers and cooking reducing risk of infections, control measures at all levesl given to eradicate
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Slaughter?
Hide removed? gastro-instesential track removed prevent contamination and splashes
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Scotland>
1996 - butchers and bakers, 17 deaths
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Findigns from 1996?
HACCP confusion, focus training, enviromental health, funding, hygiene training, primary training, non registered premises enocouraged to adopt HACCP , GMP
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Testing of E.coli
1. Intitial lab testing, phage typing (which type e.co) and pulsed field for DNA fingerprinting and then variable number tandem repeat
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How many secondary infection
48
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History of John Tudor and son
1996 run by his sons - company split into abbitor and butcehers - into J.E tudors and Sons
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Customers of Butchers
Resedential nursing and care homes, meals on wheels, day centres, restaurants, members of the public and health authorities and hospitals
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Examples of statements to police?
Cooked meat into raw section amd imsealed vac packs, preparing raw meat etc. Persons entering the cooked meats areas when the practise should not occured. Wiliam Tudor - dirty clothing - cups of tea being brought in - no stock rotain and no one was
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other failures?
No stock rotation - not protected and freezer would not be controlled. Stored in wlak in and out feezer - clear risk of contamination inside the vans
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Employees hand and clothing can be contamination - critical - replacement of food - storage of stck - un
unwrapped, mixed, cooked amongst raw chicken- movement between areas- raw meat would not change clothes
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when was the outbreak declared over?
20th December 2005
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John and william
william was son of John - William managing director
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Stock rotation details
stock going back to 1998, 2003 and 2004 absence of segregation
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Councils
Rhondda Cynnon Taf, Brigend, Caerphilly and Merthyl Tydfil Bourough council - joined together working on food procurement e.e inviting competitive teders for the supply of meat to primary and secondary schools - worth £0.5 million
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tender
2002 taking the contract throughwith extention to the contract
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why was the food poisioing not identifed by the borough concils?
LA procuremenrt procedures should take the requirements of EC Procerememt Directives -From 1st April 2000 LA in Enland and Schotland has a statitory order to provide "best value" covering product quality, customer satisfaction, and number of complain
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2004 produced guidance document on good procurement
aimed at catering managers and procurement professionals distribited by CE and LA. Contained section on due dilligence, HACCP, product qualot,
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2005
WAG published a series of case studies showcasing organisations that were leading this search for better quality. john Tudor was one of two suppliers featured in this showcase - publication by Rhondda, Cynnon Taf Borough Council
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WAG?
Welsh Assembly Goverment
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contract responsibility
One individuals responsibility to design and operatr a system of procurement which would have clear lines of responsibility and roles defined for each of the 4 parties involved - latter never completed
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Catering management Group
proceduremeent issues between catering departments - day to do links between suppliers and schools but not part of the councils procurement depart. informal and minal notes. WAG 2004 - guidance between proceurmeent and minise risks -
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RCT Borough
Drew up the tender documentation in consulation with its trading Standard Department to ensure the correct leglisation was being refered too - no discussion with EH department
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Each borough awared contracts based..
on their own decision. Carephilly BC was only one who made their iwn check about a potentional via a supplier review group. All other boroughs took a passive approach and delebgrated to RCT
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Customer complaints were processed by each individual authority
prior to the awarding contact in 2000, caerphilly has recieved severl complaints about the reciept of undercooked meat, lack of segreation of meat and use by dates, and foreign bodyes by John Tudor and Sons
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What wasn't taken into consideration?
No evidence this was taken into consideration when contracts awarded
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The meat (HACCP) regulations
2002
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HACCp regulations came into force for "small meat estbalisments2
On 7th June 2003
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OVS
Offical Vetinary Surgeon
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Chandler school ill
13th Septembr 2005
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diarrhoea and abdominal pain
14th - 17th - blood in stools , returned back to school on the Monday
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19th Septemnber
Outbreak into the media
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21st September
Mason fallen ill - high temp and headache- differnt to his brother chandler - sampels taken and kept away from school - EHO allerted - started to vomit - hot and cold
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what school?
Deri school in Rhymney Valley - 100 pupils
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22nd 24th
Starting passing blood - nappies -
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25th Setember
Positve for E.Coli 0157. Passing less urine (Kindye failture) odour was extreme and prescriped paracetamol and Iburprofen. 20.00hrs Mson worses and taken to hospitcal temp dropped to 394.9c -eyes sunk and put onto a intravenous cannula
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HUS
Haemolytic Uraemic Syndrome - disease is characterised by destruction of red blood cells and a low platelet count, effect children 5-10% mortality] - raised white blood cells indicating flammation - urea leavels high and sodium decreased- rehydration
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Transfered too?
Specialist Renal Uni
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26-27th
mason refered to renal uni - acute renal failue, Dialysis followed - neurological condition worsesned and became confused - 27th transfered to intense care, starting to fit, abdomen has started to distend - fitting (haemodialysis inititated)
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28th 3rd October
MRI scan norma - recieing haemodialysis and plasma exhange treatment and drugs - 3rd October bloodpresusre because to drop and cardian message and rescucitation procedures were cut out - blood presure droped with heart reat - circulation unresponsive
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4th October
00.30 - rescucitiation stopped - 13 days
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Death a result of
haemolytic uraemic sydrom - e.coli infection
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Illness dose
as low as 10-100 CFU
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who most volunerable
under 5's and over 75's - 2-7% effected will develop HUS whilst risk for children
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Symptoms
2-12 days
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Total cases?
157 (92% strain unqieu to the outbreak, 75% confiemed positve of E.coli 0157)
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Who owned abboitor?
Billy and John tutor since 1980's
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issues at the butcher
internatl, poor conditions, poor layout, rubbish accumulation, absense of training, in adequate risk asssement , weak HACP, cooked meat, segreationm stock rotation, clothing, written procedures, packaging, weighting scales
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Serving of inforcement notice to Tudors
2000 and two in 2005 (h&S and food safety and hygiene regulations)
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may 2005?
12 month tender contract - supplier did not renew - John Tudor and sons next
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1st April 2000
Local Authority - statitory duty to provide 'best value' covering product quality, consumer satisfaction, and number of complaints mad against contractor / supplier
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Dates of stock
1998, 2002, 2003 and 2004
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2004 WAG
Produced a guidence document between procuremenent practise aimed at catering managers and procurement. Distributed by CE and LA- best practise and minimise risk o reciptiemnts - section on due dillegence - physical insepctin HACCP, proiduct quality
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AIM
Regular communication and existing suppliers to maintain contract compliance
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2005 WAG
publisjed a case studies of showcasign orgamisations that ere leadin the search for better quality John Tudor was one - publisheing by Rhondda Cynon Taf borough Council
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4 councils supplied worked to awared cntracts
1 idvdual to design and operatre a system of procurement - clear lines of responsblites androles for each 4 partiles - never completed
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Catering manger group
Deal with food procurement between catering departments of each borugh state - links between suppliers and school - not part of councils procurement dep - informal with minomal notes/ taking
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Tender documentation RCT
tender documentation with trading standard department - to ensure all correct leglisation was being refered to but no discussion took place with EH dep with same office as TS
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Each borough awarded contracts to supplirs
Caerphilly only one who made their own checks about a potential supply via s supply review grou. --> all other took passice approach and delagred contract to RCT
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Complaints?
Individual auythoruty - prior to 2000, RCT Carephilly, servarl complaints from Johmn T about segreation, foreign bodeies and temp - known to lead procurement- not taken into account when contracts were awarded
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Who was responsible for inspecting JTS
Bridgend
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Caerphilly 2000 -
not issue contract because of quality issues
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pre-premise insepctions
1. Review information held on FA records 2. Discussion with buisness proprietors r.e. prupose of insepction, identify food realtied activiteds and layout / storage sta etc 4. Discusswith supervisotry stall - responsble for monitoring and issuing CP
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Step 4 ..
Physical inspection of hygiene (scope, recording, hazards, effectives, HACCP system, breahes, enforcement, advise and information, recomendatooms, contious improvement)
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5
food samples chem, mcro,
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6 & 7
Closing meting - hazards, CCP disucsision, recomendations
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record inspections and outcomes
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Butchers licence
2000 - HACC:
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Renewed by
Brigemnd County Borough Coucil 2000 and 20005 - pumping and tumblering operation for ham absesnt and no reference to shelf life
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Monitoring formats
not filled in dya my day - critial limits exeed - corrective actions inadequate -
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between 1998, 2001 and 2001
get away with serious risk
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how many admitted to hospita;
31
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FSA annual report 2--3- 2004
concern of MH lack of effective action and underlying filure of many operators to take responsibiliyy for their own operations
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failures of MHS
HACCp = and enforcement - prep for introcuctions nt adequate, inadequate to imderstnaidng nad training and preporation, - ignored dates by parliament of HACCP and failed to prepare adequately - inadequate training of the OVS front line enforcers.
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MS
steps taken but no t adequate, acceptable timeframe, 2003/ 2004 identified issues and did little. - MHS response that FSA nakcloged training in education
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Ecoli?

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0157

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Total of how many cases?

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Card 4

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What was the inquiry?

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Card 5

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What is E.coli 0157?

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