top of page
< Back

E.Coli in South Wales

The inquiry investigated the causes and handling of the 2005 E. coli O157 outbreak in South Wales, resulting in 24 recommendations to prevent future outbreaks

The E. coli O157 outbreak in South Wales Inquiry, officially titled The Public Inquiry into the September 2005 Outbreak of E. coli O157 in South Wales, was chaired by Professor Hugh Pennington. This outbreak was one of the largest incidents of E. coli O157 in the UK, affecting 157 people, primarily schoolchildren, and resulting in the tragic death of five-year-old Mason Jones. The inquiry began in September 2005 and concluded with the publication of the final report in March 2009, lasting approximately 38 months.


The outbreak was traced to contaminated meat supplied by John Tudor & Son, a butcher's business in Bridgend. The inquiry sought to identify the causes of the outbreak, examine the response of the relevant authorities, and make recommendations to prevent similar incidents in the future. The investigation revealed several critical failures in food safety practices, regulatory oversight, and crisis management.


One of the key findings was the inadequate hygiene practices at John Tudor & Son. The inquiry discovered that the butcher's business had poor standards of cleanliness, including cross-contamination between raw and cooked meats. These failings were compounded by a lack of proper training and supervision for the staff. The inquiry also highlighted deficiencies in the local authority's inspection and enforcement activities. Despite previous concerns about hygiene at the butcher's premises, there was a failure to take decisive action to address these issues and prevent the outbreak.


The inquiry also examined the response of the public health authorities to the outbreak. It found that the initial handling of the situation was slow and uncoordinated, leading to delays in identifying the source of the infection and implementing control measures. The report emphasized the need for better communication and coordination between different agencies to ensure a swift and effective response to future outbreaks.


As a result of its findings, the inquiry made 24 recommendations to improve food safety and public health practices. These included stricter enforcement of food hygiene regulations, better training for food handlers, and enhanced monitoring and surveillance systems. The inquiry also called for the establishment of clear protocols for managing outbreaks of foodborne illnesses and improving communication between public health agencies.


The impact of the E. coli O157 outbreak in South Wales Inquiry was significant, leading to substantial changes in food safety practices and regulations in the UK. The findings and recommendations of the inquiry helped to strengthen the overall safety of the food supply chain, enhance the response to foodborne outbreaks, and protect public health.


In one sentence: The inquiry investigated the 2005 E. coli O157 outbreak in South Wales, identifying its causes and making 24 recommendations to improve food safety and prevent future outbreaks.


Key numbers at a glance

24

Recommendations

38

Months to complete

Cost in millions      (if known)

1

Deaths (direct)

Recommendations

Recommendation

Description

Food Safety Practices

Improve food safety practices and hygiene inspections

Food Procurement

Enhance procurement processes for school meals

Health and Care Services

Strengthen health and care services for outbreak management

Schools and Hygiene

Implement better hygiene standards in schools

Learning Lessons

Learn from the outbreak to prevent future occurrences


Podcasts by Inquests and Inquiries

Podcasts by other providers

Downloadable files

Resource

Web Address

E. coli Public Inquiry Website - The National Archives

E.coli Spreads cover actual - MRSA Action UK

2005 South Wales E. coli O157 outbreak - Wikipedia


Links to other resources

Select videos

A full playlist gallery is at the bottom of the page.

Image Gallery

Video Gallery

The player below has a loaded playlist of videos related to this topic. Clicking on the fast forward/skip bottom will take you to the next video.

bottom of page