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277:
paramount. Steps must be taken at points throughout the food chain to prevent contamination and cross-contamination, particularly in abattoirs and butchers' premises that handle raw and cooked meats. The report has reinforced our belief that
William Tudor is responsible for Mason's death. I believe the inspections regimes clearly should be tightened. There is no excuse for the serious failings which occurred, which ultimately led to the
32:
204:
from the same illness. His condition gradually worsened over the next few days. The out-of-hours health service did not react immediately to his worsening condition, but he was admitted to hospital on Sunday 25 September, where he was diagnosed with kidney failure and transferred to a specialist unit in
Bristol on Monday 26 September. Despite intensive care, Mason died on Tuesday 4 October.
227:
William Tudor continued to be awarded contracts to supply meat to local schools for school meals. He had falsified records that were an important part of food safety practice and had lied to environmental health officers. In the Public
Inquiry Report, Professor Hugh Pennington said "the blame for the outbreak rests squarely on the shoulders of William Tudor".
259:
County
Borough Councils who had awarded the schools contracts to John Tudor & Sons, calling the process by which the contracts were awarded as "seriously flawed". Criticism was also levelled at the Meat Hygiene Service which had failed to enforce Meat Hygiene Regulations at the JE Tudor & Sons abattoir.
226:
The source of the outbreak was traced to meat supplied by a butcher at
Bridgend – John Tudor & Son, the proprietor of which was William Tudor. The infected meat had originated at the abattoir of William Tudor's cousin, JE. Tudor & Sons ltd. Despite several warnings by food hygiene inspectors,
172:
The first cases were identified on 16 September 2005, after 5 children had been admitted to a hospital in
Merthyr Tydfil. The earliest sign of illness had been 10 September. Most cases had originated before the end of September, though the last case of the outbreak was identified on 8 November 2005.
281:
outbreak. I am pleased with
Professor Pennington's recommendations. I am now to go away and digest the report thoroughly. The Professor has studied the evidence that has been gathered during the course of the Inquiry and has returned with very sensible recommendations. We thank him for his time and
254:
The report made 24 recommendations, 15 relating to food hygiene inspections; some of these were aimed at strengthening key HACCP (Hazard
Analysis Critical Control Points) principles and for the Food Standards Agency to review its guidance. It also recommended a substantial review of food hygiene by
164:
O157 in Wales and the second largest in the UK. 157 cases were identified in the outbreak; 31 people were hospitalized, and there was a single fatality. Most of the 157 cases identified were children, attending 44 different schools across four different local authorities – Bridgend, Merthyr Tydfil,
230:
Despite the death of Mason Jones, the Crown
Prosecution Service decided against seeking a conviction for manslaughter, and William Tudor was eventually convicted after pleading guilty to 7 food hygiene offences and was sentenced to one year in prison. He was released after serving 12 weeks of that
203:
outbreak was the death of a five-year-old named Mason Jones from Deri, Caerphilly. He had attended his local primary school and contracted the disease via a meal served at the school. He was sent home from school on
Wednesday 21 September feeling ill, shortly after his elder brother had recovered
258:
The report contained criticisms of several local administrations and food hygiene inspection procedures. Bridgend County Borough Council was ultimately responsible for the inspection of John Tudor & Son. Criticism was also levelled at Rhondda Cynon Taf, Bridgend, Caerphilly and Merthyr Tydfil
276:
O157 is a particularly nasty organism but it can be prevented from causing infection. It has not gone away; it remains a potential threat to people's health. There are no specific treatments available to prevent the onset of complications which are often severe and sometimes fatal. Prevention is
250:
The Public Inquiry included more than 45,000 pages of evidence, 258 statements from 191 witnesses, and 63 witnesses were called to the hearing. It cost £2.3 million. William Tudor did not cooperate with the inquiry, though was not compelled to do so.
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O157. In a statement to the press, she said "I just want people to know how bad this bacterium is, and how powerless I felt standing by the side of him watching him die from it".
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outbreak that killed our 5-year-old son and we now look to move on to the Inquest into our son's death where we hope the coroner will reach an appropriate verdict.
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outbreak. I agree that all businesses that are dealing with raw and cooked meats need to have in place an effective and working asset plan.
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The Outbreak Control Team was praised for controlling the outbreak, identifying the source and removing cooked meats from the food chain.
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efforts. Abattoirs' reliance on self-regulation leads to business owners cutting corners, which is what led to the tragedy such as the
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1146:
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For many of those affected, the illness progressed with a typical process of vomiting and bloody diarrhoea, sometimes leading to
1244:
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247:, who had also presided over the Inquiry into the Lanarkshire outbreak in 1996. The report was published on 19 March 2009.
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machine used to package both raw meat and cooked meat without being properly cleaned between batches, resulting in
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On Mothers Day 2014 I do not want to be standing here sympathising with another family that has lost a child to
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butcher jailed for a year. A butcher has been jailed for a year for food safety offences which led to a fatal
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Since his death, his mother, Sharon Mills, has campaigned to help raise awareness of the dangers of
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There was also criticism of the communication procedures of the out-of-hours healthcare service.
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180:. Afterwards, some of those affected spoke of long-lasting physical and psychological effects.
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Caerphily and Rhondda Cynon Taf. Of those infected, 109 cases were identified as a strain of
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8:
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Professor Pennington has come to the conclusion that William Tudor is to blame for the
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383:"The Public Inquiry into the September 2005 Outbreak of E.coli O157 in South Wales"
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Mills, Sharon: statement to the press, 20.03.09, BBC and ITN News broadcasts.
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At the press conference at the publication of the Inquiry Report:
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A memorial garden was established in at his primary school in
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NHS Counter Fraud and Security Management Service Division
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489:"Press Statement by Professor Hugh Pennington"
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1261:Centre for Occupational and Health Psychology
1256:Centre for Health and International Relations
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255:local authorities in five years (thus 2014).
1202:Cabinet Secretary for Health and Social Care
1074:2022–present National Health Service strikes
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409:Mills, Sharon: witness statement, 15.6.2006
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160:in 2005. It was the largest outbreak of
1361:Disease outbreaks in the United Kingdom
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592:2006 North American (multiple; O157:H7)
456:Hugh James – family statement 27.2.2007
319:
317:
243:into the outbreak was led by Professor
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1245:Association of Mental Health Providers
1179:2005 South Wales E. coli O157 outbreak
1039:History of the National Health Service
587:2006 North American (spinach; O157:H7)
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1094:Cardiff University School of Medicine
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345:from the original on 28 November 2010
1341:2005 disasters in the United Kingdom
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1064:Defunct district health authorities
968:Public Services Ombudsman for Wales
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432:"Memorial garden for E.coli victim"
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14:
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1099:Swansea University Medical School
505:from the original on 7 March 2023
234:
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1126:Chief Nursing Officer for Wales
1111:Chief Medical Officer for Wales
898:NHS Business Services Authority
617:2024 United Kingdom (STEC O145)
381:Pennington, Hugh (March 2009).
1297:Caerphilly Heart Disease Study
1214:Health and Care Research Wales
1121:Chief Dental Officer for Wales
1049:List of Welsh medical pioneers
762:Long-term evolution experiment
459:
450:
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169:O157 unique to this outbreak.
1:
1184:2013 Swansea measles epidemic
953:Healthcare Inspectorate Wales
918:Velindre University NHS Trust
308:
863:Health in the United Kingdom
465:BBC News coverage, 19.3.2009
7:
194:
10:
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1366:Disease outbreaks in Wales
1356:Escherichia coli outbreaks
1104:North Wales Medical School
1009:Individual funding request
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1209:UK Health Security Agency
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999:NHS treatments blacklist
1271:St John Ambulance Cymru
1219:Health Commission Wales
1167:Dragon's Heart Hospital
963:Care Inspectorate Wales
935:Welsh Ambulance Service
582:2005 South Wales (O157)
1351:2005 disease outbreaks
602:2011 Germany (O104:H4)
306:
297:
288:
222:Source of the outbreak
1059:Local board of health
298:
289:
270:
199:A consequence of the
1172:Test, Trace, Protect
1044:History of NHS Wales
973:Informing Healthcare
567:1993 Jack in the Box
341:. 7 September 2007.
1281:Wales Air Ambulance
1193:Government agencies
930:Public Health Wales
923:Welsh Blood Service
891:Local health boards
736:Verotoxin-producing
597:2009 United Kingdom
477:Public Inquiry Team
189:cross-contamination
1302:Emergency planning
1054:Sanitary districts
908:NHS Pension Scheme
696:Enteroaggregative
607:2015 United States
487:Pennington, Hugh.
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1327:
1142:COVID-19 pandemic
1089:Medical education
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981:
820:
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812:Theodor Escherich
772:Molecular biology
701:Enterohemorrhagic
438:. 13 October 2006
333:outbreak in 2005"
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102:16 September 2005
21:2005 South Wales
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903:NHS Direct Wales
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183:The cause was a
151:Escherichia coli
148:outbreak of the
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53:Escherichia coli
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25:O157:H7 outbreak
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118:Confirmed cases
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112:8 November 2005
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48:Bacteria strain
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37:Two strains of
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185:vacuum packing
178:kidney failure
154:O157 bacterium
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110:10 September –
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66:Contaminated
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1250:Autism Cymru
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572:1996 Odwalla
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507:. Retrieved
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440:. Retrieved
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393:. Retrieved
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156:occurred in
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127:Severe cases
51:
38:
22:
15:
1024:Social care
1014:EMRTS Cymru
1004:Drug Tariff
648:FNR regulon
158:South Wales
79:South Wales
1335:Categories
1266:Sight Life
913:NHS trusts
871:Healthcare
802:Rho factor
792:Pathogenic
787:Min System
752:Aerobactin
633:CPS operon
309:References
231:sentence.
1135:Epidemics
1019:Hospitals
987:Dentistry
886:NHS Wales
797:EnvZ/OmpR
560:Outbreaks
349:7 October
1320:Category
1276:Trust PA
1252:(former)
1082:Medicine
975:(former)
879:Services
716:O104:H21
500:Archived
436:BBC NEWS
343:Archived
195:Fatality
75:Location
41:O157:H7
1290:Studies
1147:UK-wide
1033:History
745:Related
731:O157:H7
721:O104:H4
688:Strains
509:30 June
442:30 June
395:30 June
302:E. coli
293:E. coli
284:E. coli
279:E. coli
274:E. coli
209:E. coli
201:E. coli
167:E. coli
162:E. coli
70:machine
57:O157:H7
39:E. coli
23:E. coli
782:LacUV5
767:EcoCyc
658:RecBCD
331:E.coli
327:E.coli
304:O157."
136:Deaths
63:Source
958:Llais
626:Genes
503:(PDF)
492:(PDF)
386:(PDF)
1162:2022
1157:2021
1152:2020
726:O121
678:RpoS
673:RpoN
668:RpoF
663:RpoE
653:OmpT
638:DnaG
511:2024
444:2024
397:2024
351:2011
239:The
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