The Fatal Accident Inquiry into the deaths of 21 elderly people in Scotland from the E.Coli bacteria published its report yesterday. After hearing over 30 days of evidence that ran into 5,777 pages of transcript, it said the tragedy was exacerbated by the "deliberate deception" and "ignorance" of a local butcher.
The outbreak of E.Coli 0157 in Lanarkshire in November 1996 was Britain's worst case of food poisoning. Several of the people who died had attended an annual church lunch in Wishaw and eaten meat provided by the local butcher, Mr John Barr. Among the others who died were residents of a local nursing home and the deaths continued until June 1997.
In a strongly-worded condemnation of Mr Barr's work practices at his shop in Wishaw, the sheriff principal, Mr Graham Cox, leading the inquiry, said the deaths of six people could have been prevented. The report concluded that if Mr Barr had responded "fully and honestly" with Environmental Health officers, by admitting he supplied meat to Scotmid supermarkets, six deaths could have been avoided. Listing five key failures by Mr Barr, the report described the deaths of the elderly victims as "undignified and often very painful". It found there was inadequate training of the staff, a failure to use temperature probes for cooking raw meat, a failure to draw up cleaning schedules, a failure to separate processes for raw and cooked meat, and to provide separate knives and equipment at each stage of processing. "Mr Barr liked to keep a clean shop and maintained a clean shop. What he failed to do was maintain a safe shop . . . " the report stated.
However, the tragedy was compounded by Mr Barr's "lack of frankness" about the true nature of his premises, which led health officers to conclude he was exempt from regulations relating to the supply of cooked meat. When the question of Mr Barr's registration under 1994 regulations arose in 1995, he told officials he supplied meat to a number of other butchers but failed to mention his supply to wholesalers. The report concluded it could not rule out the possibility that the food poisoning would not have occurred if Mr Barr had been registered.
The report said the health officers should have detected bad practices at Mr Barr's premises. "The practices in Barr's, according to John Barr, were long-standing. They were flawed . . . if they were not detected they ought to have been."
Afterwards, Mr Barr's lawyer, Mr George Moss, issued a statement saying his client would be taking time to consider the implications of the report and would not comment in the near future.
The family of one of the victims, Mr Alex Gardiner, welcomed the report saying it upheld their belief that not only were Mr Barr and his staff principally responsible for his death, but the investigation into the outbreak by North Lanarkshire Council was inadequate. The family said the next step was to establish liability for Mr Gardiner's death when they pursue a claim for damages against Mr Barr.