Report of independent inquiry into Fonterra botulism scare released

By Siouxsie Wiles 29/10/2013

Today saw the release of the report by the independent inquiry into the contamination of whey powder that lead to the Fonterra botulism scare in August this year. At 165 pages its not exactly light reading. The inquiry team, comprised of Jack Hodder QC (a lawyer), Jacob Heida (an expert in whey production processes and standards for infant food ingredients) and Gabrielle Trainor (a crisis manager), have identified what led to the scare and list 33 recommendations for Fonterra to implement as a result of the crisis. The inquiry team are also clear that “no heads should roll” as:

“the errors in judgement which might be attributed to individual employees are essentially the result of gaps in Fonterra’s procedures and training”

What went wrong?

Quite a few things, it turns out. But here are just a few of them:

1. Fonterra’s whey powder was not being manufactured to the specifications required by at least one of its customers. This relates to the lack of specific tests for sulphite-reducing clostridia (SRC) – the class of bacteria which includes Clostridium botulinum as well as other clostridial species which can cause food spoilage. SRC levels are considered a general indicator of quality of hygiene standards and one of Fonterra’s customers had specific acceptable levels for SRCs in place. This is why the final product was tested in Australia, and then rejected by the customer, when found to exceed their levels.

2. The contamination happened because a plastic torch lens broke in a batch of whey powder during an examination of part of the processing equipment. Not all of the plastic was recovered so the workers requested that the batch be downgraded to cattle feed. This request was denied and the workers told to “rework” and filter the product to remove the “foreign matter”. Alas, this was not standard operation at the plant and the workers improvised to get the job done, using a piece of stainless steel pipe that hadn’t been used for 2 years, and two flexible pieces of hose not normally used. They had all been cleaned, but not enough to remove the Clostridial biofilm living in them.

3. The commissioning, design and limits of the C. botulinum testing were inadequate.

More details on the testing are given in Appendix C, and the inquiry members hold no punches:

“The Inquiry’s view is that the AgResearch test was not capable of achieving the outcome that Fonterra wanted.”

What Fonterra wanted was: “a letter stating that these organisms are either C. sporogenes or C. botulinum and does/not have the ability to produce BoNT [toxin].” But the report states that AgResearch did not have the necessary typing methods or the toxin antidotes necessary for the mouse bioassay. In fact, they go on to say that it would appear that no laboratory in New Zealand is sufficiently qualified to carry out such testing. This will be why MPI sent the samples overseas.

What should Fonterra do about it?

You can read the full list of recommendations for yourself, but here are some of the ones I find most interesting:

1. Ensure that Fonterra’s specifications (and associated testing) for potential food quality and safety issues across nutritional product ingredients manufactured for Fonterra are of “best in class” standard: consistent with the most rigorous requirements of customers, and with international best practice. That is, don’t supply product that doesn’t match the specifications requested by your customers. (Recommendation 1 of 33)

2. Overhaul the procedures for non-routine microbiological testing within Fonterra to ensure senior management oversight of proposals for low probability/high risk internal work, and that such proposals are thoroughly assessed in advance for utility and the full range of possible consequences. That is, make sure the bosses know what non-routine tests are being commissioned and what the consequences of a positive result will be. (Recommendation 8 of 33)

3. Establish a revised protocol for engagement of external scientific and diagnostic resources to ensure that any work commissioned is by institutions or practitioners of international standing, is appropriately undertaken for, and funded by, Fonterra (i.e. asking whether the proposed work is not better undertaken on a pan-industry basis), and that the analyses sought will yield results that are robust. That is, can whoever you outsource the testing to, actually deliver and their data be reliable? (Recommendation 9 of 33).

In Appendix E, Jacob Heida states this very clearly:

“..within Fonterra, there appears to have been little knowledge of the testing procedures for C. botulinum and the botulinum toxin (BoNT). Fonterra should review its procedures to ensure that testing is outsourced to properly accredited laboratories and that results are peer reviewed.”

I’m really pleased to see peer review mentioned here. This is certainly what many of us were calling for during the crisis – show us the data and the methods! There is a little more info on AgResearch’s testing in this report – but still no real detail, other than that they did do some genetic tests (inconclusive) and that 14 mice were used.

4. Establish and sustain relationships with a pool of scientific experts in food quality and safety who can speak to the media and the public in the event of an incident. (Recommendation 16 of 33)

This is elaborated on in Appendix F:

“Scientific advice on health and safety issues should be part of the IMT’s [Incident Management Team] resources. Appropriately media trained scientific experts should be part of and available to the IMT to demystify complex data and scientific terms. Fonterra should have a pool of experts across various specialisations readily available.”

5. The Board should encourage investment by “NZ Inc” (including the NZ Government, Fonterra itself and other food products firms) in ensuring that New Zealand has pre-eminent scientific and diagnostic resources for food quality and safety purposes. That is, NZ should have accredited labs! (Recommendation 32 of 33)

Only time will tell how many of the recommendations Fonterra will implement, but its a good sign that the company chose to publish the Inquiry’s report in full instead of keeping it hidden behind closed doors. But in case they do implement recommendation 16, or other companies reading this report decide to do something similar, I urge all you scientists out there to get some media training (like the SAVVY course run by the Science Media Centre..)

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