1 May 2013
The Animal Health and Veterinary Laboratories Agency (AHVLA), an executive agency of DEFRA (Department for Environment, Food and Rural Affairs), has been censured for safety failings relating to the control of biological agents at facilities in Devon and Surrey.
The Health and Safety Executive (HSE) completed a Crown censure procedure against the Weybridge-based organisation following an investigation into the handling of samples containing Mycobacterium bovis (M. bovis) – the causative agent of bovine tuberculosis (TB), which in some circumstances can also be harmful to humans.
HSE found that over a period of more than two years, between January 2009 and July 2011, an AHVLA laboratory at Starcross, Exeter, had failed to appropriately inactivate M. bovis in samples that were subsequently sent to their Weybridge laboratory for genetic testing. Employees at Weybridge were put at serious risk because they handled the samples without suitable control measures believing they posed little risk.
Working with M. bovis in a regular laboratory in its live form can cause severe disease and so posed a potentially serious hazard to employees. It therefore requires specific containment measures in order to protect workers.
AHVLA has accepted a number of failings linked to the handling and control of samples. They include:
- Standard Operating Procedures were not fit for purpose – they lacked clarity and detail, and did not take proper account of the equipment at Starcross used to inactivate M. bovis, or the experience of personnel at that laboratory.
- The wrong equipment was provided – the equipment provided to the staff at Starcross for the M. bovis inactivation procedure was not the right equipment for the task.
- Training for Starcross technicians was inadequate – personnel undertaking the M. bovis inactivation procedure received no formal training on the process.
- Effectiveness of the inactivation process was not monitored – personnel at Starcross did not routinely check that the inactivation process was working and that the M. bovis samples were safe to handle.
- Managers failed to resolve issues – some operators at Starcross raised concerns about the inactivation process and equipment, but no action was taken.
AHVLA Chief Executive Chris Hadkiss attended the censure at HSE’s Basingstoke Office on Monday (29 April) to accept the findings on behalf of AHVLA. In doing so the agency has formally acknowledged there were health and safety failings.
Crown bodies, such as AHVLA, must comply with the requirements of the Health and Safety at Work etc, Act 1974. They are, however, excluded from the provisions for statutory enforcement, including prosecution and penalties.
A ‘Crown censure’ is the formal recording of a decision by HSE that, but for the Crown immunity, the evidence of a Crown body’s failure to comply with health and safety law would have been sufficient to provide a realistic prospect of conviction.
HM Specialist Inspector Dr Keith Stephenson, HSE’s lead investigator in this case, said:
"HSE’s investigation at AHVLA, which resulted in the Crown censure, identified several serious failings that led to the potential exposure of a number of AHVLA employees to M. bovis over a period of more than two years. Exposure to M. bovis can be a serious health hazard.
"The evidence brought to light by the HSE investigation would be sufficient to provide a realistic prospect of a court conviction against the agency. This censure is the maximum enforcement action that HSE can take and should serve to illustrate how seriously HSE take the failings that were identified at AHVLA."
The Crown censure proceedings relate to AHVLA’s discharge of its duties as an employer under Section 2 of the Health and Safety at Work etc Act 1974.
Notes to editors
- The Health and Safety Executive is Britain’s national regulator for workplace health and safety. It aims to reduce work-related death, injury and ill health. It does so through research, information and advice; promoting training; new or revised regulations and codes of practice; and working with local authority partners by inspection, investigation and enforcement. www.hse.gov.uk
- A Crown censure is the maximum sanction for a government body that HSE can bring. There is no financial penalty associated with Crown censure, but once accepted is an official record of a failing to meet the standards set out in law. More information can be found here: http://www.hse.gov.uk/enforce/enforcementguide/investigation/approving-enforcement.htm
- For the purposes of working with biological agents in the laboratory, Mycobacterium bovis is categorised by the Advisory Committee for Dangerous Pathogens as a Hazard Group 3 biological agent, which requires handling in a Containment Level 3 laboratory to protect the health of workers. More information can be found on Categorisation and Containment Levels at http://www.hse.gov.uk/pubns/misc208.pdf and http://www.hse.gov.uk/pubns/priced/microbiologyiac.pdf.
- M. bovis in the natural environment. Defra considers the risk of people contracting Tubercolosis (TB) from cattle in Great Britain as very low. At present, less than 1% of all confirmed cases of TB in humans are due to infection with bovine TB. This view is supported by the Health Protection Agency, now Public Health England, who identify the current risk posed by bovine TB to human health as negligible. Information on the public health risks from bovine TB can be found at: http://www.defra.gov.uk/animal-diseases/a-z/bovine-tb/public