Food poisoning outbreaks demonstrating management failures

Food poisoning outbreaks demonstrating management failures

Staphylococcus Aureus

Ten people develop symptoms after eating rolls filled with egg mayonnaise. Three people were admitted to hospital. The filling had been made from hard-boiled eggs. After chopping, these eggs had been left overnight in a refrigerator which had been too warm, as a result of loss of refrigerant. The filled rolls had been placed in a ‘refrigerated’ display counter which was non-operative, the ambient temperature being 25° C. The source of the outbreak was the food handler who had prepared the eggs while suffering from a skin infection. Although a ‘classic’ outbreak involving contamination from a food handler and inadequate temperature control, the underlying cause was the lack of equipment maintenance. This contributed significantly to the out break. Management also failed to recognise the hazards of inadequate temperature control and failed to realise that a food handler with a skin condition could present a serious hazard.



A hospital outbreak resulted in the death of three people and 119 cases of food poisoning. The vehicle of infection was roast lamb which had been cooked the day before it was served and had been left covered with cloths in a hospital corridor because of the ‘sultry evening’. Conditions were considered ‘abousltely perfect for bacterial multiplication’. The total consignment of 25 joints of lamb had been pre-cooked because the ovens were being repaired the following day. The hospital refrigerators were not used because they were full of jellies which would have not set at room temperature. The coroner was ‘satisfied’ this was an isolated incident, when someone had not ‘gone by the book’. At some stage the roast lamb had become contaminated and there had been a ‘classic’ failure of temperature control. However, the underlying cause was clearly the failure of management to plan for the contingency of the oven repairs and to make satisfactory alternative arrangements. 


Clostridium perfringens

In a hospital outbreak, patients in one of six wards who were served with roast meat and gravy succumbed to Clostridium perfrigens food poisoning. Unaccountably, none of the patients in the other wards suffered, even though they had apparently been served the same meal. On investigation, however, it transpired that the chef had run out of gravy towards the end of serving and had quickly made up additional stock fro the stock pot, without having had time to cook the mixtures thoroughly. Further investigation showed that ingredient planning had been deficient in that there had been no specific quantities set out for a given number of meals. Quantities prepared were left to the judgement of the chef who estimated what was needed on an ad hoc basis. There were no established procedures, written or otherwise.


Clostridium botulinum

In June 1989 a botulism outbreak affected 27 people and one person died. The implicated product was hazelnut yogurt. The contamination was traced to the manufacturer of canned hazelnut puree used in the yogurt. The manufacture was more used to producing high-acid fruit purees, in which the acidity from the fruit suppressed the growth of botulinum bacteria. However, he had employed the same process to make hazelnut puree. But this was a low-acid product, presenting a completely different order of risk. Changes to the ingredients were also made. Before the recipe had been changed, a full risk assessment should have been carried out.