Sheriff Principal Graham Cox, in the report from the fatal accident inquiry, ruled that had Mr Barr responded "fully and honestly" with officials investigating the November 1996 outbreak, then six lives might have been saved, because the supply of cold meats to wholesalers could have been prevented.
But experts warned yesterday that another such tragedy is inevitable unless standards are improved. "The Lanarkshire case is not an isolated one and is really the tip of the iceberg," said Dr Richard North, who was an expert witness at the inquiry. "There are a great many other cases out there which go undetected and we need to look at the whole system of food hygiene controls in this country."
Paul Santoni, a lawyer representing the family of Alex Gardiner, 69, one of the victims, welcomed the apportioning of blame in the report. He said: "There appears to have been an ethos of `no blame, no responsibility' from John Barr and North Lanarkshire Council. In my view North Lanarkshire Council reacted negatively against all our criticisms made during the inquiry.
"Hopefully now from this disaster we may have learning and successes in combating and controlling future episodes, otherwise the deaths and subsequent pain and suffering will be doubly wasted."
All of the dead came from Lanarkshire and central Scotland. They included pensioners who had attended the same church lunch and residents of a nursing home at Banknock in central Scotland. The sheriff said they died after "undignified and often very painful illness".
In a withering attack both on Mr Barr and on the practices used at his shop, the sheriff said that at the 37-day inquiry Mr Barr had been untruthful "whenever it suited him". He added: "I have no doubt Mr John Barr liked a clean shop and maintained a clean shop.
"What he failed to do was to maintain a safe shop and the main ingredient of his failure was ignorance of the requirements which would produce that result."
He had paid "lip service" to environmental health officers (EHOs) visiting his shop and concealed the full extent of his business, which also supplied meat to supermarkets. But the EHOs were also criticised for failing to spot the hazards inherent in the operation of the premises.
The inquiry ruled that there were five key failures which led to the outbreak. There was inadequate training of staff at Mr Barr's shop in Caledonian Road, Wishaw, implicated in the outbreak.
There was also a failure to use temperature probes for cooking raw meat, a failure to draw up cleaning schedules to reduce the risk of contamination at the premises and a failure to separate completely within the premises processes relating to raw meat and cooked meat.
In particular, ruled the sheriff, there was a failure to provide separate knives and equipment for each of the separate processes. The butcher's shop also failed to provide clear management structures and "adequate supervision" to enforce safety measures.
Yesterday Mr Barr said through his representatives that he had no immediate comment to make on the findings.Reuse content