Learning From Major Incidents Cadbury Salmonella Outbreak Nick Lowe Food Safety Team Leader
Learning From Major Incidents Cadbury Salmonella Outbreak Nick Lowe Food Safety Team Leader Birmingham City Council Introduction Cadbury & Chocolate Making Initial Stage Preliminary Investigations Main Investigation Discussion Points – Home Authority Perspective Cadbury Multi National food company Number of sites in UK Chocolate making, chocolate products Supply of goods to other manufacturers Head office in Birmingham (Bournville) COCOA BEANS MILK SUGAR COCOA LIQUOR CHIRK MARLBROOK COCOA POWDER 3RD PARTY SALES CRUMB BOURNVILLE COCOA BUTTER CHOCOLATE PRODUCTS Initial Stage June 2006 FSA notified us of Product Withdrawal National Increase in Salmonella Montevideo S. Montevideo found in Cadbury products Suggestion that Cadbury were aware of Salmonella but still distributed product. Questions How could this happen? Explanation for release of product Lack of notification, liaison Any on-going problems? Have all the affected products been identified, could others be involved? Preliminary Investigation - Process Crumb arrives in tankers from Marlbrook, sample taken prior to departure Emptied into one silo Manufactured into product within 24 hours Affected crumb/chocolate distributed throughout the factory What went wrong? S. Montevideo found in crumb at Marlbrook Later attributed to a leaking drainpipe When result obtained crumb already made into chocolate product. No positive release of crumb What went wrong? What happened if Salmonella found in crumb or liquid chocolate +ve/-ve, +ve/+ve Increase in end product sampling 2 per line per shift 4 per line per shift – 100% increase From 52 samples to 104 300 tonnes of chocolate produced 60,000,000 50g bars What went wrong? S. Montevideo in end product Most Probable Number (MPN) Mike Pusey report – 2003 BCCCA Microbiological risk analysis for the biscuit, cake, chocolate and confectionary industry. Key Questions Validity of MPN? Validity of +ve/-ve, +ve/+ve? Interpretation of Pusey Report? Role of Campden & Chorleywood? Lack of notification? Nagging Question What prompted the introduction of the MPN policy? 3 Salmonella incidences between April 2002 and January 2003 All product disposed of Internal Report – Wells Report Nagging Question Project Ivan Project Jade (Somerdale) What about A-H? May 03 – S. Montevideo CDM 49g MPN – release of product Jan 04 - S. Montevideo in crumb, no source identified, release of product March 04 - S. Carmel CDM 49g MPN – release of product June 04 - S. Montevideo in crumb, no source identified, release of product Jan 05 – Project Alex, Salmonella in crumb, release of product March 05 – Project Becks, S. Carmel in double decker, MPN – release of product April 05 – Project Charlie, S. Carmel in drinking chocolate, MPN – release of product April 05 – Project Donald, S. Carmel in double decker, MPN – release of product April 05 – Project Eden, S. Brackenridge in double decker with nuts, MPN – release of product May 05 – Project Flash, S. Brackenridge in Curly Wurly, MPN – release of product June 05 – Project Gomez, S. Brookfield in CDM buttons MPN – release of product Oct 05 – Project Hector, S. Bonariensis in Curly Wurly, MPN – release of product Main Investigation Five key areas of investigation What evidence do we need? How are we going to get it? What have we achieved? Project Campden Advice/instruction given to Cadbury by Campden about Salmonella MPN procedure – appropriateness Copies of notes of meetings, reports, letters, e-mails Microbiological results going back to 2002 Project Campden Search under warrant Seizure of records, including computer records Statements from key personnel Project Probable ACMSF nominated witness Salmonella/MPN/any other relevant discussion ACMSF minutes to be introduced Project Probable Interview with Professor Hunter MPN suitable for homogenous spread of bacteria Not suitable for Salmonella, chocolate +ve/-ve, +ve/+ve discredited Misinterpretation of Pusey Report Project HPA Expert Witnesses – outbreak, chocolate samples Introduction of epidemiological evidence Contact with Campden/FSA Reference to published guidance Project HPA Interview with 4 key witnesses at Colindale PFGE, gel plates, DNA match Project OB Cases Identify OB cases Witness statements from OB cases Identification via HPA Visit and interview witnesses Project Cadbury Company details Introduction of MPN Consultation Challenge PACE interview Refused Joint Working Routine outbreak meetings Clear roles set FSA – recall Herefordshire – hygiene at Marlbrook Birmingham – corporate decision making HPA – epidemiological investigation, distribution of samples, outbreak control team ACMSF – expert opinion Health Protection Agency Essential support for investigation Joint visits Key witnesses – epidemiological evidence, expert opinion, counter Cadburys expert witness Contact with cases Health Protection Agency Access to patient information Medical confidentiality
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