- Carole Cross died 16 years after the 1988 Camelford health scandal
- Driver accidentally poured 20,000 tonnes of aluminium sulphate into water
- Mrs Cross, 59, found with very high levels of the metal in her brain
- Widower calls for more tests to determine long-term effects of the disaster
- Dr Cross: 'Verdict comes after eight years of fighting to discover the truth'
- Customers reported rashes, diarrhoea and mouth ulcers after using water
- But South West Water did not tell public about the cause for TWO WEEKS
- Insisted it was safe and even 'gave advice that increased levels of aluminium'
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Ingested aluminium: An undated photograph of Carole Cross, whose inquest ruled that there was a 'very real possibility' she died from a disease caused by a mass water poisoning in 1988
A coroner criticised a water authority today for 'gambling' with the lives of 20,000 people by not telling them for more than a fortnight about Britain's worst mass poisoning.
West Somerset Coroner Michael Rose criticised the South West Water Authority as he gave his verdict on the death of Carole Cross.
Mrs Cross, 59, died in 2004 from a rare disorder usually associated with much older people suffering from Alzheimer's disease.
She had been living in the Camelford area of north Cornwall in July 1988 when the poisoning occurred.
She was one of 20,000 customers affected when a relief lorry driver mistakenly added 20,000 tonnes of aluminium sulphate to the drinking water at the Lowermoor treatment works.
The coroner 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.
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.
The inquest was told that, for more than two weeks, South West Water Authority, which ran the treatment works, did not tell the public the cause of the poisoning and insisted 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.
Customers 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.
Source: Camelford water treatment works, where a relief driver triggered the health crisis in 1988 when he mistakenly poured 20,000 tonnes of aluminium sulphate into the drinking water
Widespread risk: The alumininium sulphate was then pumped into the water system to South West Water Authority's 20,000 customers
Mrs Cross, who lived on the outskirts of the town and later moved to Dulverton in Somerset, died in Taunton's Musgrove Park Hospital.
She suffered from a rare neurological disease - cerebral amyloid angiopathy.
Her husband, Dr Doug Cross, believes her exposure to high levels of aluminium during the incident caused her death 16 years later.
Professor Chris Exley, a reader in bioinorganic chemistry at Keele University, who has studied the effects of aluminium for 25 years, told the inquest the aluminium found Mrs Cross's brain was a factor in her death.
He told the inquest in 2010 it was 'highly likely' the high concentrations of aluminium in Mrs Cross's brain contributed to the early onset of the disease.
Mrs Cross's husband, Dr Doug Cross (left), welcomed the verdict by coroner Michael Rose (right) and called for more research into effects of the poisoning on other residents who ingested water during the poisoning
And, giving evidence last week when the inquest resumed after a break of more than a year, he said: 'The amount of aluminium in her brain is of an order rarely seen and only seen previously seen in cases of aluminium toxicity.'
He added that he had studied samples of more than 100 brains and 'Carole Cross has the record' in terms of amounts of the metal.
His evidence in 2010 and that of Margaret Esiri, emeritus professor of neuropathology at the University of Oxford, prompted an adjournment to allow South West Water Authority time to seek its own expert evidence.
Dr Cross, who now lives in Cumbria, did not attend today's hearing in Taunton, Somerset.
Acted responsibly: The coroner said lorry driver John Stevens should not be vilified for his mistake. he instead laid blame on procedures at the water authority which he said were an 'accident waiting to happen'
Mr Rose said: 'From July 9 for a few days Mrs Cross ingested a quantity of aluminium, precise measurements of which are not possible, because of the failure of the authority to ensure the public were encouraged to give urine and blood samples.
'I also 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.
'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 the delivery driver putting 20 tonnes of aluminium in the wrong tank at the unattended treatment works was 'an accident waiting to happen'.
'I do not think that relief driver John Stephens should be vilified,' the coroner said.
'He struck me as a conscientious man who tried to use his initiative and had acted responsibly.
'It was an accident waiting to happen though, whether or not the procedure in the Fowey district differed greatly from those in the other five districts of the authority, or indeed in other authorities across the country, I do not know.
'Clearly the safety devices to prevent this mistake causing further trouble were not in place.'
Mr Rose said that after the incident he was concerned that South West Water Authority did not have an emergency call-out system for water treatment works staff.
However, he said he would not criticise the authority for not stopping the water supply to Camelford, having heard strong evidence of the effect of doing so.
Mr Rose said that two days after the incident senior staff and authority chairman Keith Court were aware that aluminium poisoning was the likely cause.
He said he was 'surprised' no one contacted Mr Stephens until July 12 - six days after the incident - to find out where he had put the aluminium sulphate.
'This was a totally unacceptable delay,' Mr Rose said.
'At that stage either late on the Friday evening or even on the Saturday, the relevant public health officials should have been told the full facts.
'What I do have problems with was the failure to advise the public health authorities of the real problem and also the fact is that the public were not told for 16 days that aluminium sulphate had been put in the water supply.'
No prevention measures: Mr Rose said it was clear there were no safety devices to prevent this kind of mistake from occurring at the plant
WORRYING CHAIN OF EVENTS: HOW THE POISONING CRISIS UNFOLDED
Britain's worst water poisoning incident happened in the north Cornwall town of Camelford 22 years ago.
This is how events unfolded:
1988, July 6: A relief driver dumps 20 tonnes of aluminium sulphate into the wrong tank at the then South West Water Authority's water treatment works at Lowermoor, Cornwall.
Water supplies to 20,000 people in the Camelford area are affected by the pollution.
In the days that follow, residents complain of green hair, vomiting, bowel problems, short-term memory loss, joint pains and allergies.
July 21: A notice is placed in a local newspaper telling the public what happened 15 days earlier. This is the first public acknowledgement of a problem.
1989: A Government inquiry concludes it is unlikely there will be any long-term health effects.
1991: A second Government inquiry refers to the possibility of 'unforeseen late consequences'.
The then South West Water Authority goes on trial at Exeter Crown Court and is fined 10,000 with 25,000 costs for supplying water likely to endanger public health.
1995: A group of 148 victims of the incident reaches an out-of-court settlement, with payments ranging from 680 to 10,000.
1999: An article in the British Medical Journal says it is 'highly probable' that the aluminium poisoning did cause brain damage in some people.
2001: The Department of Health appoints an eight-strong team to investigate whether there are any long-term health effects.
2005: A draft report published by the Committee on Toxicity Lowermoor Sub-Group says it is unlikely there will be any persistent or delayed health effects.
The final report has yet to be published.
2010: November: West Somerset Coroner Michael Rose begins an inquest into the death of Carole Cross.
Professor Chris Exley says that the aluminium found in the 598-year-old's brain was a factor in her death.
His evidence and that of Margaret Esiri, emeritus professor of neuropathology at the University of Oxford, prompts an adjournment to allow South West Water Authority time to seek its own expert evidence.
2012, March 5: The coroner resumes Mrs Cross's inquest, and adjourns after two days of evidence to consider his verdict.
March 14: Mr Rose records a narrative verdict and criticises the South West Water Authority for its 'dereliction of duty' after 'gambling' with the lives of 20,000 people.
He also says there is a 'very real possibility' that the ingestion of aluminium by Mrs Cross had contributed to her death.
Mr Rose blamed South West Water Authority's 'poor state of management' for the delay in telling health officials of the disaster.
'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.'
Mr Rose said the decision not to tell the public of the mass poisoning until July 21 was in the 'mistaken belief' that the flushing of the system that had occurred in the days following the incident had removed the excessive aluminium from the drinking water.
'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,' Mr Rose said.
'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 said he had concerns about the actions at the time of the incident of the then authority chairman, Mr Court, who died after the resumption of the inquest.
'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.
'This may partly be explained by the fact that Mr Court came into the industry from outside and had no practical experience of the problems that could arise or was misled by reports that the problem had been overcome.'
The coroner said there was no reason for anyone living in Camelford at the time of the disaster to fear they might also become a victim.
'I have little doubt the overwhelming number of residents in July 1988 ingested little or no aluminium,' Mr Rose said.
'The case of Mrs Cross was decided on very specific facts which are unlikely to be replicated elsewhere, save possibly in some exceptional circumstances.'
Mr Rose also said that, during the course of holding the inquest into Mrs Cross's death, he had become aware of a 'lacuna' in coronial law which could, if not corrected, result in a 'miscarriage of justice'.
'I am therefore recommending to the Government that they make a payment to Somerset County Council of a sum not exceeding 150,000 to cover the costs of holding this inquest,' Mr Rose said.
'This was an inquest where the cause of the deceased's death was believed to have arisen in Cornwall and had no connection with Somerset other than the deceased died here.
'I am also asking the Ministry of Justice to open discussions with the Coroner's Society with a view to setting down the criteria by which they wholly or partially finance complex inquests as there does appear to be considerable variation in practice.
'I am a little surprised this help was not forthcoming for what has been said by the authority's own expert as the worst public water system poisoning incident anywhere.'
After the inquest, Dr Cross called for further research into the effects of the disaster on the people living in the Cornish town.
'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 read by his spokesman.
'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.'
Water supplies in Devon and Cornwall are now provided by South West Water.
The company purchased publicly run South West Water Authority a year after the disaster in September 1989 when the water industry was privatised.
James King, head of drinking water services at South West Water, said: 'Water treatment at Lowermoor and indeed every other works in the UK has been transformed since the privatisation of the water industry in 1989 due to rigorous regulation by the Drinking Water Inspectorate and heavy investment on better security, equipment, monitoring, fail-safe processes and training.
'For example, site access and chemical deliveries are always strictly controlled. Continual monitoring and quality alarm systems now provide real-time information which can be acted upon within seconds to tackle any problem which might arise and if necessary shut down a works.
'This transformation over two decades means the South West now regularly records new highs in water quality and Britain as a whole continues to have world-leading tap water which is safe to drink.'
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