National Assembly for Wales Press Release, 6 January 2006
A copy of the report is available on this site at: Report on South Wales E.coli Outbreak
A report into the South Wales E.coli outbreak has made 22 recommendations to reduce the risk of it happening again.
The review by Wales ' Acting Chief Medical Officer, Dr David Salter, looked at the systems and processes in place before and during the outbreak to ensure any immediate lessons are learned and applied. It was limited in what it could look into because of the ongoing South Wales Police investigation.
The report makes a number of recommendations to the Food Standards Agency, local authorities, the National Public Health Service for Wales, the Wales Centre for Health and the Welsh Assembly Government.
The report makes eight recommendations for the Food Standards Agency (FSA). It calls on the FSA to review existing food legislation and guidance to local authorities in relation to how often they should inspect premises and whether there is any need for further legislation. It will also need to look at whether the local authority correctly applied this legislation in relation to the premises of John Tudor and Son.
There are seven recommendations for local authorities, including the need for them to work closely with the FSA to introduce any new measures to improve food hygiene and to look at whether they have enough staff to deal with a food poison or infection outbreak. It also calls on councils to review how they arrange school cleaning, in particular toilets and to ensure pupils have access to soap and hot water.
There are three recommendations for the National Public Health Service (NPHS) and the Outbreak Control team. These include the need for them to consider alternative forms of communicating to the public other than through the media. The NPHS should make greater use of its website so the public can access the latest accurate information on an outbreak. It also calls on the NPHS to ensure that for large outbreaks, a full written report is completed and published as soon as possible to ensure we can continually learn from experience.
Among the three recommendations for the Welsh Assembly Government, the report calls for a Steering Group to be set up to ensure that all the recommendations are taken forward and implemented. It also says the Assembly Government should work to resolve the difficulties of trying to run a review alongside a police investigation.
The report also recommends that the Wales Centre for Health should work closely with the Outbreak Control Team in helping to improve communication with the public during an outbreak.
The Chief Medical Officer, Dr David Salter, said:
"The outbreak affected 158 people, mostly children, one of whom sadly died. The South Wales E. coli outbreak was the largest Wales has seen and it was essential that we looked at what happened and learned any lessons as soon as possible. The review team, led by my colleague Dr Mike Simmons, has identified 22 recommendations that will help us learn from this experience and put in place measures to reduce the risk of it happening again."
Health Minister Dr Brian Gibbons added:
"I would like to thank Dr Salter and his team for the speed with which they completed this comprehensive report into the outbreak. It is important that all organisations identified in the report take on board the recommendations and take steps to implement them as soon as possible. For the Assembly Government's part, I accept the recommendation to set up a Steering Group to monitor progress on the report's recommendations. I will now consider who will need to be part of the group. I will also make this report available to Professor Hugh Pennington and his inquiry who will no doubt find it useful. I would also like to take this opportunity to thank all members of the Outbreak Control Team for their hard work and dedication in responding to and effectively managing the outbreak."
The Terms of Reference for the Review were as follows:
"To review the arrangements in place for the protection of public health and food safety immediately before and during the outbreak of E.coli infection in South Wales commencing September 2005 and to advise the Welsh Assembly Government immediately, as the review progresses, on any changes it recommends.
The areas to be considered will include:
The Review will take full account of the report of the Expert Group chaired by Professor Hugh Pennington into the 1996 outbreak in Central Scotland of infection with E.coli. The Review Team will be chaired by the Deputy Chief Medical Officer, Dr Mike Simmons."
The Review Group was established on 24 October 2005 and included:
The report can be found on the Chief Medical Officer's website at www.cmo.wales.gov.uk
The South Wales E.coli outbreak