Terms of Reference for the Investigation

The Terms of Reference for the Independent Investigation agreed by the Board of the Health Protection Agency were to look at the factors which contributed to the cause of the Godstone Farm outbreak and to review its subsequent handling by the Health Protection Agency and others. This included but was not limited to:

1. The characteristics of E. coli O157 and factors affecting its transmission from animals to humans in the context of Open Farms
2. The standards which apply to the operation of Open Farms (including relevant guidance and how this was made operational)
3. The operation of Godstone Farm with reference to these standards
4. The regulatory oversight of Open Farms in general and Godstone Farm in particular
5. The responses to the outbreak from all those involved following the identification of illness in people who had visited Godstone Farm (including the advice given by the Health Protection Agency)
6. The responses to other outbreaks of E. coli O157 which have been linked to similar Open Farm facilities

The Investigation would consider any lessons to be learned from the experiences and best practice of the devolved administrations, and relevant evidence from public authorities in other countries.

The Investigation would also ensure that the families of those affected by the outbreak were invited to have an input.

The Report of the Investigation would be presented to the Board of the Health Protection Agency and, once accepted, would be made public.

Pending the final report, any interim recommendations requiring urgent action to protect public health would be published as soon as possible.