Worked examples

Worked examples

Peanuts

These examples are based on ground almonds' contamination with ground peanuts.

Five incidents involving severe allergic reactions in consumers to foods purchased from restaurants and takeaways were identified and investigated.

Each incident had been investigated in isolation. Root Cause Analysis would help to gain a better understanding of the true reasons why these incidents occurred.

The incidents

INCIDENT COMMENTS
An individual suffered an allergic reaction following consumption of a meal believed to contain ‘ground almond’ - the individual was peanut allergic. The individual believed it was peanut free as they had eaten two similar meals in the previous week.
An individual suffered an allergic reaction following consumption of a meal. Ground almonds were used to produce the product, which was found to contain peanut - the individual was peanut allergic.
Investigation identified mislabelling by a distributor - ‘groundnut’ mix relabelled as 'almond powder mix'.
The prosecution was completed - the root cause was not identified. Mislabelling could be deliberate for financial gain or lack of knowledge of the meaning of 'groundnut'.
An individual consumed cake sold as peanut free. The individual was peanut allergic. Test results indicated there was peanut content in the cake. Prosecution made - root cause not understood due to lack of information of raw material traceability. Issue could be due to human error or ingredient mislabelling.
An individual suffered a fatal allergic reaction following consumption of a meal and was nut allergic - death not found to be of a suspicious nature. No grounds for prosecution as a 'peanut free' meal was not asked for - meal not tested for peanuts (stored frozen).
An individual suffered an allergic reaction following consumption of a meal - the individual was peanut allergic. Prosecution made – root cause not known.

In each of these incidents, the Root Cause was not identified as each issue was contained, rather than preventing a recurrence.

See how the 5 Whys could have been implemented for these examples.

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