What went wrong at Godstone Farm?
A popular petting farm was the cause of the largest ever outbreak of E. coli linked to animal contact.
Following visits to the attraction at the end of last summer more than 90 people were struck down with the bug, which causes diarrhoea and can lead to kidney damage. But how did it happen?
Godstone Farm lies in the heart of Surrey, where the outskirts of London meet the rolling hills of the south east.
It is one of the oldest and busiest children's farms in the country, seeing up to 2,000 visitors a day during the summer.
The centre of the farm is the main barn where children used to be able to pet cows, goats and sheep. It was even not unknown for them to climb in with the animals.
That has now all changed. Visitors are no longer allowed to walk through the barn. Instead, they are led to a viewing area where they can see but not touch the animals.
Tests following the outbreak last year showed 23 of the 28 animals inside the barn were carrying the potentially fatal O157 strain of E. coli. Traces of the bug were also found on gates and fences too.
In effect, the centrepiece of the attraction was crawling with the bug.
The farm was criticised for its practices by the independent investigation into the outbreak.
It had adopted a system of deep litter, whereby clean straw is piled on top of soiled straw so that pens do not have to be cleaned out for months on end.Infections
Godstone was not the only farm to use such a method, but the experts were clear such practices had to end if children were to be allowed near animals.
But if the farm was culpable so too were the regulatory agencies.
The first visitors are thought to have been infected in early August 2009, but because it can take more than a week for symptoms to appear it was not until the end of the month before officials realised there was a problem.
By Friday 28 August, both the local council, Tandridge, and regional branch of the Health Protection Agency (HPA) were aware of several cases connected to the farm.
But despite it being the start of a busy bank holiday weekend, no visit was made and no restrictions were put in place.
That weekend more than 5,000 people visited the farm, many no doubt passing through the main barn.
It was not until 4 September that the farm itself closed its barns, which was followed by the full closure of the attraction on 12 September.
The inquiry believes part of the problem was the lack of recognition by the HPA of the seriousness of the outbreak.
An outbreak control team, which is meant to co-ordinate the response during serious outbreaks including alerting the health service to look out for symptoms, did not meet for the first time until 7 September.
It concluded there was "no ongoing risk" and set its next meeting for the end of the following working week.
In the meantime, parents with ill children were being told by GPs and hospital staff that their children just had stomach bugs.
Of course, they did not. At one point all the specialist kidney beds for children in London were taken up by victims of the outbreak.
Even now, some children are struggling to recover and may end up requiring kidney transplants in the future. As the inquiry itself said, public safety was neglected.
And with parents planning to take legal action following publication of the inquiry report, the fall-out is set to continue.