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From: TSS ()
Date: September 17, 2005 at 2:01 pm PST

In Reply to: OLDER CATTLE TO ENTER FOOD CHAIN SUBJECT TO SAFEGUARDS posted by TSS on September 15, 2005 at 12:47 pm:


Inquiry into the failure to comply with
the requirements to test all relevant
24–30 month old casualty animals for BSE


1. In May 2004 it was reported as a result of an internal audit check, that the Meat
Hygiene Service (MHS) had failed to ensure that all eligible 24-30 month old casualty
cattle in Great Britain were being tested for BSE in accordance with a requirement laid
down by the Department of Environment, Food and Rural Affairs (Defra). As a result
of this finding, the Board of the Food Standards Agency (FSA), which has overall
responsibility for the performance of the MHS, requested that a full independent
inquiry be undertaken as quickly as possible. The Department of Agriculture and Rural
Development (DARD) in Northern Ireland requested that similar failures which had
occurred in Northern Ireland also be investigated as part of the inquiry.
2. The terms of reference of the inquiry were:
i. To investigate:
(a) the reasons for the Meat Hygiene Service’s (MHS) and Department of
Agriculture and Rural Development’s (DARD) failure to ensure that animals
were tested in accordance with the instructions issued;
(b) why these failures were not identified earlier;
ii. To make recommendations to improve the robustness of the testing arrangements
so as to minimise the likelihood of this, or a similar problem, recurring;
and, to make a report to the FSA Board and DARD by the end of September 2004.
3. The aim of the MHS, which is an Executive Agency of the FSA, is to safeguard public
health and animal welfare through enforcement of hygiene, inspection and welfare
regulations in slaughterhouses in GB. In doing this the MHS undertakes a range of
food safety, animal welfare and disease surveillance activities on behalf of the FSA and
Defra. These activities, and the way they are carried out, are set out in more detail in
Annex A. The identification of casualty animals for BSE testing, which is an EU
requirement, is one of the tasks undertaken by the MHS for Defra and the work
required in this case is set out in a Service Level Agreement (SLA). It is backed up by
further detailed instructions issued to MHS staff. Official Veterinary Surgeons at
slaughterhouses are responsible for identifying animals requiring BSE testing at
ante-mortem inspection.
4. A Steering Group, whose membership is at Annex B, was asked by the Agency to
oversee the inquiry with the investigation being undertaken on their behalf by the
independent expert auditors PKF. The results of the Steering Group’s findings in
relation to DARD are reported separately.
The scale of the problem
5. Following the reporting by the MHS in May 2004 of four incidents where cattle were
not tested in accordance with instructions set out in the MHS Operations Manual, the
MHS senior management instigated a full investigation to determine if other cattle
should have been tested. The investigation revealed that in GB there were 128
confirmed cases (representing 6.2% of recorded tests shown to be required by MHS
records) that had not been tested according to the instructions and 133 possible
further cases.
The food safety risk
6. On the basis of expert advice from SEAC, the risk to human health if all 24–30 month
old casualty animals were to enter the food chain untested is considered to be very
small. There have been no confirmed cases of BSE in cattle under 30 months of age in
the UK since 1996. Cattle over 30 months do not enter the food chain, and in addition
Specified Risk Material (SRM) controls are applied. There have also been no BSE
positives detected in the more than 2,800 of the 24–30 month old casualty cattle tested
to date in the UK.
7. The Steering Group considers that these failures are in contrast to the MHS delivery of
the requirement to remove specified risk material (SRM). The auditors PKF found that
the instruction for SRM removal was clear and unambiguous, the priority given to it by
the MHS was very high, good training was provided, supervision was in place,
monitoring was rigorous and there were strong sanctions for those not in full
The investigation
8. PKF were asked by the Steering Group to seek answers to the questions set out in
Annex C by auditing a number of GB plants by site visits and through an extensive
telephone survey of plant Official Veterinary Surgeons (OVSs) at other plants.
Independent Local Authority members of the UK Illegal Meat Task Force1 carried out
the telephone survey. Details of the investigation and PKF’s findings and conclusions
are given in the PKF report at Annex D.
9. PKF reviewed other matters of relevance to the testing arrangements including liaison
between the FSA, MHS and Defra, the procedures for monitoring of MHS performance
by the FSA and Defra’s arrangement for monitoring of the MHS’s compliance with the
terms of the SLA. Key managers and staff in Defra, FSA, MHS and various of the OVS
Contractors were interviewed. In GB, independent contractors employ over 90% of
OVSs in plants.
1 Established and funded by the FSA.
10. PKF visited nine GB plants (five where testing failures had been detected and four
where there had been no failures recorded) to undertake detailed plant audits. The
GB plants visited spanned all MHS regions and included high- and low-throughput
premises and included a plant where the OVS was directly employed by the MHS and
plants where OVSs were supplied by Contractors (eight plants).
11. Telephone survey responses from a further 191 OVSs in GB plants were analysed to
supplement the findings of the more detailed abattoir audits.
EU testing requirements
12. The requirement was for the surveillance of animals which might be at increased risk
of BSE. The first instruction to OVSs was issued in December 2001 and applied from 1
January 2002 in GB. The EU requirement (Annex E) is to test for BSE all 24 to 30
month old cattle that are slaughtered for human consumption if:
• They are subject to special emergency slaughtering
• Slaughter has been deferred2 at ante-mortem because the animal is suspected of
suffering from a disease communicable to man and animals, or showing symptoms
of disease or of a disorder of the general conditions which is likely to make their
meat unfit for human consumption.
GB testing requirements
13. In GB Defra has overall policy responsibility for BSE testing. As indicated above, the
MHS carries out the relevant functions in slaughterhouses, for Defra, their customer. A
SLA (Annex F) between MHS and Defra specifies the testing requirements. The MHS
has a Chief Executive who is responsible for the day to day operations of the MHS
including the deployment of resources. As the MHS is an Executive Agency of the FSA,
the FSA is accountable for the overall performance of the MHS.
14. The current GB instruction for testing 24-30 month old cattle is set out in Annex G.
FSA legal advice is that this instruction goes beyond EU requirements by requiring that
all 24–30 month old cattle that during ante-mortem inspection, are identified as
showing signs of any disease, injury or abnormality are tested.
The delay in identifying failures
15. The Steering Group has considered the information gathered by PKF and considers
that the identification of the failures was delayed as a result of inadequate technical
supervision and monitoring of OVSs by Contractors and the MHS, together with the
omission of this function from the audit programme agreed by the FSA and Defra.
2 Animals which are put aside to be slaughtered separately so that they can be subjected to more detailed postmortem
16. There may have been more failures than those identified against the current GB
requirement, as it is clear from the PKF investigation that some OVSs have been using
their own judgement as to what should be tested, and not recording minor injuries or
abnormalities. The exact level of failure to test against the current instruction cannot
therefore be determined with any certainty, as no records exist for these animals.
17. However the Steering Group considers that the current GB requirement for testing was
not practical to implement in all circumstances.
Reasons for the failures
18. The Steering Group has considered the findings of the PKF investigation and
concludes that there were a number of reasons for the GB testing failures and that all
organisations involved – FSA, Defra, MHS, and their Contractors contributed to the
failure to one degree or another.
19. It is the view of the Group that the failures occurred principally because the
requirements and the objectives of testing were not clearly agreed nor communicated
effectively, and not properly monitored by Contractors or the MHS.
20. Where the cattle are known or suspected to be diseased or injured, the farmer is
required to prepare a Schedule 18 Certificate to accompany the animal to slaughter.
This is to give adequate warning of the animal’s condition to the slaughterhouse
operator. Sixty-three per cent of the failures were accompanied by Schedule 18
Declarations that should have been seen by the OVSs and led to testing.
21. Where cattle are killed on farm, the farmer is required to ensure that a Schedule 19
Certificate is signed by a veterinary surgeon and accompanies the carcase to a
slaughterhouse. Nine of the failures concerned were animals slaughtered on the farm.
The Group consider that there can be no excuse for Schedule 18 and 19 animals not
having been tested.
22. The Group has concluded that there were a number of factors that led to a systems
failure of the testing requirement. These were:
• The lack of specific measures of technical performance or standards in the
Defra/MHS Service Level Agreement (SLA).
• That the instruction was not communicated effectively. The instruction was
changed on five occasions and the most significant change, which removed
flexibility in interpretation of the instruction by withdrawing the right of the
OVS to exercise professional judgement, was not flagged as a key change. The
arrangements for providing guidance to OVSs were inconsistent and did not
recognise the importance of the instruction.
• That where OVSs sought further guidance the response was often inconsistent and
this contributed to variations in the implementation of the instruction.
• That the instruction was not practical to implement in all circumstances. The
instruction required, in its final form, the detection and testing of all 24–30 month
old cattle that during ante-mortem inspection are identified as showing signs of any
disease, injury or abnormality, no matter how insignificant. This appears to exceed
the requirement of the EC Regulation.
• That there was an inadequate supervisory structure for OVSs, who often lacked
monitoring and support and consequently were often isolated. Some of the OVSs
involved, particularly those trained abroad, were clinically inexperienced and not
familiar with GB slaughterhouse practices. They needed a higher level of training,
guidance and support than was available whether from the MHS (in the case of
directly employed OVSs), or from their employer (where this was a Contractor).
• That there was insufficient monitoring of performance against the requirements of
the SLA by either Defra or by the MHS, with no agreed performance indicators to
establish the quality of the service to be provided. The SLA did not identify a key
performance indicator against which the standards of testing being delivered could
be checked.
• That there was insufficient training of OVSs by the Contractors in the case of OVSs
supplied by them or the MHS in the case of directly employed OVSs.
• That there was no formal cross-checking arrangements between the results of
ante-mortem and post-mortem inspections, as identified by PKF. The post-mortem
examination of all animals could have acted as a means of picking up animals
which should have been identified for testing when inspected in the lairage, but
which were missed.
• That there was no means by which an OVS would know when a Schedule 18 had
been submitted to the plant operator but not passed on to them.
Testing priority. ...


Causes of testing omissions
Specifically the testing omissions occurred as a result of OVSs not identifying all relevant
animals for testing, either by the inappropriate exercise of professional judgement or by
matters not spotted at the ante-mortem stage.
The failures to test arose as a result of a combination of the following factors:
• The requirement was seen by OVSs, MHS, FSA and Defra as being primarily for
disease surveillance and not food safety. This meant that it was perceived as a
lower priority for ensuring compliance and the arrangements for implementing it
were designed accordingly.
• There was a lack of clarity as to what was required. The instruction was changed
on 5 occasions and the most significant change, which removed professional
judgement, was flagged as a reminder rather than a key change. The mechanisms
for communicating the instruction were ineffective and the arrangements for
providing guidance to OVSs were inconsistent and did not recognise the
importance of the instruction.
• The final version of the instruction conflicted with OVS views as to what reflected
a BSE risk and implied a detail of ante-mortem inspection that was much greater
than previously carried out in order to identify sign of any disease, injury or
abnormality – this was not practical at the larger plants as the design and
operational arrangements limit the visibility of individual animals and the
throughput demands limit the time available.
• There was inadequate supervision and monitoring of OVS records or activity to
identify that the instruction had not been met. When the POVS role was removed
the level of alternative supervision was not increased and this remains an issue.
• There is no cross check between the results of the ante-mortem and post-mortem
inspections. This could have identified further animals with injuries and
abnormalities that were not being identified at the ante-mortem stage. The lack of
a formal check was exacerbated by the OVS and MHIs not working as a team.
• The Service Level Agreement did not identify testing activity as a key performance
indicator. MHS monitoring was driven by the key performance measures.
• There was no expectation of testing levels by MHS or Defra and therefore no
mechanism to identify that tests were being missed.
• Many of the OVSs involved were inexperienced and in need of a higher level of
training, support and guidance than was available. In some cases this may have
been exacerbated by unfamiliarity with the GB system and language difficulties.
The designation training for OVSs is considered to be insufficient by MHS,
Contractors and OVSs and many also feel that subsequent training is not enough to
assist them to carry out their role.
Delay in identifying testing omissions
Identification of the failures was delayed as a result of a lack of effective technical
supervision and monitoring by Contractors and MHS. Initially reliance was placed on the
POVS, but this was ineffective as POVSs did not understand the requirements themselves
and varied in their effectiveness as supervisors. Since the removal of the POVS role in 2002,
responsibility for supervision has been delegated to Contractors without technical MHS
check. Again the structure has failed on this issue as the Contractors did not understand the
FSA and Defra relied on FSA audit of the application of the Manual by the MHS. However
this particular testing requirement was not included in the audit work specified or carried
out as it was not identified as a high priority for check.
Records of ante-mortem and testing activity are paper based and held locally. They do not
facilitate easy checking of completeness of tests nor easy analysis of data. Reporting within
MHS has therefore tended to focus on exceptions rather than giving fuller information. The
matter was eventually identified when MHS introduced its own internal audit function. The
testing failures identified are likely to have been only part of those missed as OVSs
interviewed indicated that they do not always record minor injuries on the ante-mortem
The Key Performance Indicators (KPIs) focus upon administrative matters and there was no
effective measurement or monitoring of technical standards, or of technical performance.
Measurement of such qualitative matters is limited – the performance of MHS was not
monitored by Defra, the Contractors performance was not monitored by MHS.
Current areas of risk of BSE testing omissions
Action taken since the discovery of the failures has heightened awareness of the issue and
improved the specific skills, thereby reducing the likelihood of errors on Schedule 18 and 19
cattle. However, human error will mean that without an effective check mechanism some
missed tests may still arise. Of more concern is the continuing vulnerability to delayed or
lost Schedule 18 certificates and the difficulty for the ante-mortem inspection process in
identifying all the animals meeting the requirement for testing.
The GB testing requirement appears to exceed that required by the EU regulation, as the last
change to it was introduced in order to increase the numbers tested rather than to meet a
technical requirement of the regulation. It also appears to be impractical to achieve at some
plants without increasing the resource available to carry out the ante-mortem inspection.
This needs to be considered in the arrangements going forward.


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