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