Butcher William John Tudor sold rotten meat for years, according to testimony in a coroner’s inquest in Wales this week, but that did not lead to a verdict against him for unlawful killing.

Instead, Gwent coroner David Bowen said five-year old Mason Jones’ death during the 2005 outbreak of E. coli O157:H7 in Wales was the result of a systematic failure.  He said stricter food controls are needed.

“Mason’s death was the result of an E. coli infection probably due to the consumption of cooked meat which had become contaminated during the course of preparation due to a lack of or disregard for good food hygiene practices,” Bowen said.

Bowen called for an “urgent review” of the mechanism for food hygiene regulations enforcement, more frequent inspections of abattoirs, and stricter compliance with food hygiene regulations.  

John Tudor and Sons butchers in Bridgend supplied meat to about 40 schools in South Wales, including young Mason’s primary school.  Contaminated gammon and turkey the youngster ate at school left him infected with E. coli O157:H7.  After two weeks of suffering, the boy died.

“The strain which killed Mason was indistinguishable from the strain found in unused cooked meat supplied to schools by William Tudor,” the coroner said.

The 2005 outbreak of E. coli O157:H7 was the largest ever in Wales and second largest in the United Kingdom.  More than 150 became infected, and 31 required hospitalization.  Like Mason Jones, most of the victims were children.

An independent inquiry led by Professor Hugh Pennington last year issued its report and recommendations.

Since the outbreak, the 56-year old Tudor has served one year in jail after admitting to six counts of placing unsafe food on the market and one count of failing to protect food from the risk of contamination.

Bowen, the coroner, opted to give a “narrative verdict” that will be shared with both the Welsh Assembly and the Ministry of Justice rather than ruling that Mason’s death was an “unlawful killing.”

Sharon Mills, Mason’s 36-year old mother, wept during the reading of the coroner’s verdict.