A water authority was criticised today for its “dereliction of duty” after “gambling” with the lives of 20,000 people following Britain's worst mass poisoning.
Coroner Michael Rose criticised the now defunct South West Water Authority for keeping quiet and not telling the residents of Camelford, north Cornwall, that 20,000 tonnes of aluminium sulphate had mistakenly been added to the drinking water.
The coroner spoke out branding the poisoning an "accident waiting to happen", as he recorded a narrative verdict into the death of Carole Cross, 59, who was living locally at the time of the incident.
The disaster at the Lowermoor treatment works in July 1988 occurred when a relief lorry driver dumped the chemical in the wrong tank at the deserted yard.
Members of the public were not told for 16 days of the cause of the poisoning with the Authority insisting the water was safe to drink.
Many people reported rashes, diarrhoea, mouth ulcers and other health problems after drinking the water or bathing in it.
The water became so polluted in the first few hours that customers reported hairs sticking to their body like superglue as they got out of the bath.
Residents flooded the switchboard of the water authority but were told it was safe and it has been claimed some were even advised to boil the water, which increased the levels of aluminium still further.
In the years that followed, Mrs Cross began to experience deteriorating health and she died in hospital in Taunton, Somerset in 2004 aged 59.
It was only after her death that it was found she was suffering from the rare neurological disorder cerebral amyloid angiopathy, which is usually associated with much older people with Alzheimer's disease.
Her husband, Dr Doug Cross, believes her exposure to high levels of aluminium sulphate during the incident caused her death.
The inquest, which first began in November 2010, heard that a post-mortem examination later found high levels of aluminium in Mrs Cross's brain. Experts said this was a factor in her death.
Mr Rose, who is the Coroner for West Somerset, recorded a lengthy narrative verdict in which he said there was a "very real possibility" that the ingestion of aluminium by Mrs Cross had contributed to her death.
"I regard the failure of the Authority to visit every house after the incident to advise them to thoroughly flush their systems as a serious dereliction of duty," he said.
"At the end of the day, I can say that the incident may either have contributed to or possibly caused Mrs Cross's death, but I do not have sufficient evidence to say so conclusively."
Mr Rose said it was a "totally unacceptable" that for six days no one contacted the lorry driver to find out what he had done with his delivery.
And he blamed the Authority's "poor state of management" for the delay in telling public health officials and residents.
"Misleading notices were given (to the public), some suggesting at the beginning that the water was safe, other notices stating that it should be boiled," Mr Rose said.
"Even after it was known that aluminium sulphate had been in the water, customers were told that if their supply was palatable, it was safe to drink.
"There are of course few people who can say that at one stage of their lives they have not kept quiet about a serious error they have made in the hope that either it would not be detected or more likely they had been able to remedy the error and no one was worse for it.
"However, in the present case they were in fact gambling with as many as 20,000 lives.
"As only a few people knew the real effect of aluminium going into the public water supply, such information should not have been withheld."
Mr Rose also criticised the Authority chairman Keith Court for not informing customers of the poisoning and suggested the forthcoming privatisation of the water industry as the reason.
"At the end of the day I had no real explanation why he had not ensured that the relevant public health authorities were advised of the problem," Mr Rose said.
"I found there was a deliberate policy to not advise the public of the true nature until some 16 days after the occurrence of the incident.
"Although Mr Court strongly denied the forthcoming privatisation of the industry was a factor that he took into consideration, I still have the deepest suspicion that perhaps it was even subconsciously, though I fully accept there was no discussion between the more senior officers of the authority to this effect."
However, the coroner also stressed that there was no reason for anyone living in Camelford at the time of the disaster to fear they might also become a victim.
Dr Cross, who now lives in Cumbria, did not attend today's hearing in Taunton, Somerset but called for further research into aluminium poisoning.
"Today's verdict comes after eight years of fighting to discover the truth about what happened to my wife Carole," Dr Cross said in a statement.
"I wish to express my gratitude to Professors Chris Exley and Margaret Esiri whose support throughout these hearings has been invaluable.
"I hope today's verdict prompts further study of the long-term effects of the Camelford incident to give reassurance to my friends and neighbours in the town."