The reliability of the family's food histories collected by health and medical professionals
93The infectious diseases section of Westmead Hospital became involved when the cluster of illnesses presented to the hospitals. On 27 October 2005, at about 11pm, Dr Kevin Lai, the staff specialist in the Westmead emergency department, notified the Sydney West Centre for Population Health, which administers the notifiable disease programme, that there were patients in the Children's Hospital and in Fairfield Hospital who represented a cluster of diarrhoea or illness in a family. This notification was made before Mr Samaan was admitted to hospital.
94On 28 October 2005, Ms Jennifer Paterson, an infectious diseases surveillance officer with Sydney West Centre for Population Health telephoned Mr Samaan to arrange an interview. She noticed that Mr Samaan's recall of the family's food history was poor (transcript 2 August 2010, at 587) and in cross examination Ms Paterson recalled that at the interview Mr Samaan was agitated and upset.
95Mr Samaan recounted his first interview with Ms Paterson in the following way (transcript 19 July 2010, at 142):
"Q. And you knew, did you not, that Ms Paterson when she saw you on 28 October wanted to identify the source of the infection?
A. INTERPRETER: Sure, yes, and I was trying to help her to know the truth.
Q. She was anxious to identify the food which caused your family's illness, was she not?
A. INTERPRETER: Yes, so she can help other people before it spreads too.
Q. And you knew that Mr Crone was anxious to identify the source of the infection, did you not?
A. INTERPRETER: Yes.
Q. And you gave them details of what you say you had eaten in the days before you became ill?
A. INTERPRETER: Yes.
Q. Did you try to help Ms Paterson and Mr Crone in their enquiries?
A. I'm pretty sure I tried a lot but I was in a position where all my kids were sick somewhere. My brain was in shock.
Q. On the first visit, that is the visit of Ms Paterson on 28 October when she questioned you, was there an interpreter present?
A. INTERPRETER: No, there wasn't because she came another time. Because she came another time, that's why. I think that's why she came another time.
Q. You understood the questions Ms Paterson put to you on the first visit, did you?
A. INTERPRETER: I nearly understood it, there was a non-official interpreter.
Q. There was an interpreter there, wasn't there?
A. INTERPRETER: Just one, just one but he wasn't very strong in interpreting, he was our cousin.
Q. He was who --
A. INTERPRETER: Our cousin.
...
Q. Just to be clear about this, the first occasion you say an interpreter was a family member, right?
A. INTERPRETER: Yes. He wasn't an interpreter, a real interpreter, he was 50/50 and he interpreted as he would but she came a second time."
96On 29 October 2005, Mr Samaan discharged himself from hospital, against medical advice, to be near his wife and Monika. He described his state of mind at the time (second further evidentiary statement of Amanwail Samaan, dated 22 June 2009):
"2.I recall that Jennifer Paterson came to interview me the day after I was admitted to hospital. As far as I can recall when I was interviewed by a woman who I am told is Jennifer Paterson on the first occasion she was not accompanied by an interpreter. During that interview I was still very sick with Salmonella poisoning, I was dehydrated and had diarrhoea and vomiting. I recall having to stop the interview more than once to go to the toilet.
3.The second time Jennifer Paterson came to see me she was accompanied by a man who I am told is Stephen Crone. This was several days after the first interview and by that time I had ripped the intravenous drip out of my arm and discharged myself from hospital. I was distraught that my family and in particular Monika was dying and I felt useless lying in a hospital bed. I wanted to be with them and to help them in any way I could.
4.I do not recall the questions that Jennifer Paterson and Steven Crone asked me and I do not recall anything about the interpreter they used other than that she was a woman. I was ill and extremely upset and worried by Monika's illness.
5.At that time I was still sick and feeling unwell and my thoughts were with my family and in particular Monika. I was not focused on the cause of the food poisoning and I was certainly not focused on the interview.
6.My native language is Sudanese Arabic. This is a totally different dialect to Arabic spoken in other parts of the Middle East such as Lebanon or Syria and the Gulf States eg Saudi Arabia, Kuwait etc. I have some difficulty understanding speakers of Arabic from countries other than Sudan and Egypt."
97On 1 November 2005, Ms Paterson emailed (exhibit TB1(1) at 525) Marianne Tegal at the Food Authority about the family's health problems and stated:
"Dear Marianne,
SSW [South Sydney West] were notified of a family with gastro that has been reported to you...Three of the four people ill have S.typhimurium grown on stool culture, the fourth is to have a sample collected.
On Friday, 28/10/5, via interpreter, I spoke with the father about their clinical symptoms, onsets (25/10) & exposures.
Recall was not great but three sources of chicken were stated -
*Raw chicken breast (fried at home) from Baida, Fairfield
*BBQ chicken from a BBQ chicken shop in the same street within a block of the Police Station
*KFC chicken burger from Woodville Rd, Villawood.
There was a teleconference this morning with Patrick Maywood, Stephen Crone, Melissa Irwin, Barbara Telfer, Oanh Nguyen and myself. We discussed chicken sources and would appreciate if the food authority could investigate these three premises. We understand that there have been quite a few recent complaints about KFC and Baida had an issue last year.
Regards Jenny"
98Patrick Maywood is an infectious disease surveillance officer for Sydney South West; Melissa Irwin and Barbara Telfer are members of the enteric diseases team at North Sydney; and Oanh Nguyen a colleague at the Parramatta office.
99Almost two hours later, Ms Paterson followed up a request from Marianne Tegal for more and better information about the premises where the chicken was purchased as she did not believe there were any retail outlets called Baida. Ms Paterson's email response was as follows:
"Dear Marianne,
Of course Stephen and I will try to get more information tomorrow. Unfortunately the father did not recall the street address nor the name of the BBQ chicken shop, only how he got there.
The father said Baida Fairfield was a well known market, and he said the BBQ chicken shop was within one block back from the police station in the same street, walking away from the train station. My guess from the map is Smart Street, looking in white pages - Chicken Express, Neeta City, Smart Street, Fairfield meet the criteria ...
Yes, the father reported that he, his wife, his two children and the paternal grandmother all had chicken burgers, chips and orange juice at KFC Fairfield.
Regards Jenny"
100On 2 November 2005, Ms Paterson and Mr Crone interviewed Mrs Shanoda. They brought an interpreter with them. Mrs Shanoda was not sharing a hospital room with any other patient. Mr Samaan, Mrs Dous, two brothers and a sister of Mr Samaan were present during the interview. In Ms Paterson's and Mr Crone's opinions Mr Samaan appeared agitated, angry, upset, distracted and concerned for his family.
101Ms Paterson recorded (transcript 2 August 2010, at 522 - 524) that Mrs Shanoda had for Sunday breakfast a "salad and chicken burger cooked at home, tomato, lettuce, cucumber". If this were correct, this would be a common meal between all members of the family and in fact this is the assumption Ms Paterson made after the interview.
102Ms Paterson was cross examined about the interview and her impressions from that time are recorded as follows:
"Q. Then on the Sunday, you record her [Mrs Shanoda] as having had for breakfast a "salad and chicken burger cooked at home, tomato, lettuce, cucumber". Just stay there for a moment, elsewhere in your investigation of this matter, let me take you to page 543, at the top of the page you have written "hospital food, eaten by Hanna during her stay", do you see that?
A. Yes.
Q. Don't you agree that you are probably mistaken in recording that on Sunday 23 October for breakfast whilst in hospital, Mrs Samaan had a salad and chicken burger cooked at home, tomato, lettuce, and cucumber, don't you agree that is probably a mistake?
A. No, because I am taking down what the family is telling me, and meals were what they were saying to me is that meals were being taken in to Hanna in hospital.
Q. So between breakfast and lunch as you understood it from the family, Mrs Samaan had Lebanese bread from a Lebanese shop but with no sauce, is that right?
A. Yes.
Q. And then for lunch on that day, Mrs Samaan had "barbecue chicken from shop, wife only ate, brought into hospital by husband"?
A. Yes.
Q. That was from a shop called Habib Bankstown?
A. Yes.
Q. And then for dinner that night, Mrs Samaan had chicken schnitzel, cooked" who cooked that?
A. I haven't read who cooked, just that it was cooked and "in morning to Hanna".
Q. So she had on that day according to the food history that you got, breakfast cooked from home. Between breakfast and lunch, Lebanese bread from a Lebanese shop, barbecue chicken for lunch that was brought in for her and in the evening the schnitzel that had been cooked that morning. So each of her meals on the Sunday according to the food history you and Mr Crone got was brought in to her at the hospital?
A. That's what we were told, yes.
Q. That's what you understood?
A. Yes.
Q. What about the food history for the Saturday, page 542?
A. There wasn't a record that was eaten on that day, so that's why it was blank.
Q. This is you and Mr Crone interviewing the whole family, the husband, the wife and --
A. And the grandmother.
Q. And were there other people in the room as well?
A. The other people in the room did not contribute to the conversation.
Q. Were they not able to tell you anything about the food on the Saturday--
A. That's correct.
Q. Or were they tired, or did you not understand it, what was the position? Why is that blank?
A. Well as I said there was no record of what was eaten that day.
Q. You could not possibly have been satisfied that the recall as described on Sunday was accurate, could you? You could not possibly have been satisfied of that?
A. I am not sure how to answer that question.
HIS HONOUR
Q. He is putting to you a proposition which you can comment on?
A. Okay. So as far as my opinion about what is satisfactory, anyone trying to recall what they have eaten is difficult. Any of us in the room if we are trying to recall what we had four days ago may not recall. Satisfactory in terms of an investigation if that's what you are asking? Ideally it is great to have a good food history, to be able to tie together what is a probable source and to prevent other people from getting sick from a probable source, to try and prevent further spread of an illness. That is an ideal, yes, if that's what you are asking.
BARTLEY
Q. But in this particular case you have noted a number of times how difficult it is to get a food history, is that right?
A. Yes, that's true.
Q. You told his Honour already about the highly emotional state the family members were in?
A. Yes.
Q. The difficulty in concentration and being distracted, you have told his Honour about that?
A. I have told the Court about my opinion of that and I have answered to the words that you have used, yes.
...
Q. Ms Paterson, having taken you through this document, the case questionnaire that is headed Mother, you cannot say, can you, as you sit there which parts of the information came from Mr Samaan and which parts came from Mrs Samaan[Mrs Shanoda]?
A. No, because it is not my purpose to separate those."
103On 3 November 2005, Ms Paterson emailed the results of the interview to the Enteric group, Ms Tegal, Mr Maywood and Mr Crone. The email stated:
"Dear All,
Stephen Crone & I spoke with the family via interpreter at Westmead Hospital yesterday afternoon. The paternal grandmother, mother and father were present (as well as two brothers and a sister of the father).
...
There were no common meals stated on Friday 21/10 when she went into labour about 5pm and was admitted to Bankstown [sic] Hospital about 8pm. However there was mention of some feta cheese and cold meats consumed by Hanna [Mrs Shanoda] that may have been consumed at different times that day by the children and father. Around that time the paternal grandmother came to stay (and care for the 2 children).
The mother ate hospital food except for BBQ chicken brought in by her husband and consumed only by her AND *** Sunday evening her husband took a "chicken schnitzel and salad burger" he had cooked at home that he and the children had also eaten that morning. (When I interviewed the father on Friday, he stated that there were chicken burgers consumed on Monday morning by the whole family from the meal prepared on Sunday as well).
...
There are remnants of all these foods being kept at their home. ... NFA intend to obtain these foods for testing, Stephen Crone and I think KFC is off the hook (anyway, the daughter had a twister and the other family members had chicken burgers).
...
Regards Jenny"
104Barbara Telfer replied to the email on 3 November 2011 and stated:
"...Sounds like Baiada at Fairfield is still a bit of a mystery, ...
Reckon its worth keeping KFC on the radar just in case..."
105Bearing in mind the language difficulties faced between the parties, and looking closely at the wording of Ms Paterson's notes, the notes suggest that the chicken burger cooked "in [the] morning [and given] to Hanna" was actually the biftek cooked on Saturday and brought to her that day. Mrs Shanoda, Mr Samaan and Mrs Dous all gave evidence in varying forms that two chicken meals were brought to Mrs Shanoda in hospital - a barbeque chicken and a home cooked chicken. The parties could not remember what was brought on which day, although Mrs Shanoda's evidence seems to be the clearest in this regard (transcript 26 July 2010 from 272 - examination in chief):
"Q. What food did you eat when you were in the hospital?
A. INTERPRETER: Sometimes they brought meat, sometimes they brought fish. Which day are you talking about, is it Monday?
Q. When you were at the hospital did you eat hospital food?
A. INTERPRETER: On Monday, yes.
Q. On each day?
A. INTERPRETER: Yes, everyday in hospital I ate hospital food.
Q. Did your husband bring you any food?
A. INTERPRETER: Yes.
Q. What food did he bring you in the hospital?
A. INTERPRETER: He brought Biftek, like schnitzel.
Q. And did you eat that?
A. INTERPRETER: No.
Q. Why not?
A. INTERPRETER: I had already eaten hospital food.
Q. What did you do with the schnitzel?
A. INTERPRETER: I threw it in the rubbish.
Q. In front of him?
A. INTERPRETER: No, not in front of him.
Q. Did he bring you any other food in hospital?
A. INTERPRETER: Yes.
Q. What other food did he bring you?
A. INTERPRETER: He brought barbecue chicken.
Q. Did you eat that?
A. INTERPRETER: No.
Q. What did you do with that?
A. INTERPRETER: I threw it out still.
Q. Why?
A. INTERPRETER: I had enough food from the hospital. They usually bring in enough food.
Q. Did you throw it out in front of your husband?
A. INTERPRETER: No.
Q. Was the schnitzel on one day and the chicken on another day, the barbecue chicken?
A. INTERPRETER: Yes.
Q. Which was first?
A. INTERPRETER: Schnitzel was first and then the barbecue chicken.
Q. Was the barbecue chicken on the next day after the schnitzel?
A. INTERPRETER: Yes, it was the day after.
Q. Why was your husband bringing you food?
A. INTERPRETER: This is our tradition from Sudan. When a woman gives birth he brings her food to feed her. It is a happy thing to do."
106In cross examination from page 297 onwards Mrs Shanoda stated:
"Q. Did they ask you about food that your husband took to the hospital?
A. INTERPRETER: No, they didn't ask me.
Q. Did you say to these two people, "My husband, Mr Samaan, brought in a barbecue chicken purchased from a shop in Bankstown to me in Bankstown Hospital for lunch on Sunday 23 October and only I consumed that chicken meal."
A. INTERPRETER: I said that at the hospital?
Q. Yes.
A. INTERPRETER: Which hospital?
Q. To the two government people on 2 November 2005 at Westmead Hospital?
A. INTERPRETER: No, I didn't say these words. I said my husband bought food but I didn't say these words and I didn't eat it, I threw it out.
Q. I suggest to you you told these people that your husband bought food and you ate it?
A. INTERPRETER: I can't remember such words. All I remember is what we said. My husband told them, my husband is the one who spoke, not me. I didn't speak. He said he bought barbecue chicken and he bought it to me and he also brought to the hospital some schnitzel. He said all this, not me. I didn't say anything like that.
Q. You said he brought in some chicken schnitzel which you ate, didn't you?
A. INTERPRETER: Barbecue or schnitzel?
Q. Schnitzel.
A. INTERPRETER: Yes, he did bring it but I didn't eat it. I didn't speak at all in hospital. He sat and he spoke with them.
Q. I suggest that you told them that you ate chicken schnitzel which your husband took to the hospital on the evening of Sunday 23 October. What do you say about that?
A. INTERPRETER: Who did I say it to, to John the interpreter?
...
Q. And did Mr Samaan say [to Mr Crone] this or words to this effect that he bought KFC meals in Villawood which were eaten between 1 and 3 o'clock on Monday?
A. INTERPRETER: Where and who did he say this to?
Q. To Mr Crone the Government man?
A. INTERPRETER: I don't know. I was sick and tired. I didn't hear all this but definitely they would have talked to him about what we ate and what we bought.
...
A. INTERPRETER: I can't remember this. I was sick and in pain and had just given birth. But I remember he told him I had cooked biftek schnitzel and "I took some to my wife in hospital as well" but he didn't think I threw it out. We didn't say anything about this.
...
Q. Did you tell her [Dr Nhan] that you received the usual hospital food, that would be in Bankstown Hospital up to Monday afternoon?
A. INTERPRETER: I can't remember these words.
Q. Did you tell her that your husband prepared a biftek dish on Sunday?
A. INTERPRETER: I can't remember these things. I can't remember these words.
Q. Well I suggest you said to this doctor that your husband prepared a chicken or biftek dish on Sunday and cooked it on Monday when you were at home?
A. INTERPRETER: It's true he did cook a biftek chicken schnitzel dish but I can't remember telling anyone this information.
Q. And he prepared it on Sunday?
A. INTERPRETER: That schnitzel he brought to me on Saturday.
Q. Did you tell this doctor that he prepared a biftek dish on Sunday and cooked it on Monday when you were at home?
A. INTERPRETER: No.
Q. Did you tell her that your mother-in-law also had dinner with the family but is well?
A. INTERPRETER: No."
107Mrs Dous and Mr Samaan both gave evidence that they did not observe Mrs Shanoda eating any of the chicken they had brought to her in hospital. Mr Crone confirmed in cross examination (transcript 3 August 2010, at 614 - 615) that Mr Samaan had never said to him that he (Mr Samaan) had observed Mrs Shanoda eat the meals he took to her.
108The inconsistencies in the evidence can be explained by the language difficulties and it is understandable that Mrs Shandona, while on the face of it, was compliant in assisting Ms Paterson, was not really concerned or fully comprehending the importance of being accurate in her recollections.
109The evidence of Ms Paterson was, when properly understood, not inconsistent with Mrs Shanoda's oral testimony. Essentially the task being performed by Ms Paterson (and Mr Crone) was the identification of the possible sources of Salmonella poisoning. Their purpose was not to differentiate between which person provided information (transcript 2 August 2010, at 526.35 -39), but, rather, to ascertain possible sources of the bacteria. The history taken reflects that purpose, as does the inability to obtain any food history for the Saturday reflect the insignificance of the Saturday/Sunday differentiation.
110The notes taken by the responsible officer do not identify the source of the information given, but aggregates the information from all sources. The circumstances then pertaining, including the general panic and worry, the language difficulties and the relationship between the persons, drawn from their culture, strongly suggest, as was the evidence of Mr Samaan and Mrs Shanoda, that it was Mr Samaan who gave Ms Paterson the information she recorded in the notes, and not Mrs Shanoda.
111Further, Mrs Shanoda's non-disclosure of what she ate in hospital could be considered in light of Mrs Shanoda's evidence that it is a Sundanese tradition for a man to bring a woman food after she has had their child. It tends to be human nature to act graciously when receiving gifts and it is therefore conceivable that Mrs Shanoda might not have wanted to admit to throwing away or not eating food that had been brought to her in front of the very people who brought it. However, this proposition was not put to Mrs Shanoda in Court and the Court should therefore not place too much weight on the possibility.
112Having said that, Ms Paterson's notes record a large quantity of food that Mrs Shanoda supposedly consumed at the hospital on Sunday, in addition to the hospital food: breakfast cooked from home, brunch of Lebanese bread from a Lebanese shop, barbecue chicken for lunch and in the evening, the schnitzel. While is likely that these meals were delivered over the course of her stay in hospital it should be remembered that hospitals are busy places. Mrs Shanoda was understandably tired and feeling unwell, thus she would naturally be trying to rest; she was caring for a new baby; she was most likely receiving regular visits from hospital staff such as doctors, nurses, cleaners, community services and possibly other visitors; and she would have been presented with regular meals that are designed to be eaten easily.
113The chicken and other food provided by the family would have been more cumbersome for a hospital patient to consume. For example, it is unlikely that Mrs Shanoda would have had cutlery outside of that provided with the hospital meals and during the periods when she did have cutlery, there would have been little space on a hospital bed tray to either break up or tear apart the meals with her hands or set them out in front of her while she was eating. It is not inconceivable that Mrs Shanoda only ate hospital food. It would have been hot or warm and easier to eat. It would seem the most logical, appealing and convenient food and for these reasons I prefer Mrs Shanoda's evidence given in Court that she did not eat the food her family brought to her while she was in hospital.
114On 3 November 2005, Brett Campbell, a senior food safety officer with NSW Food Authority, visited Mr Samaan at home to obtain leftover food samples from him for Salmonella analysis. Mr Campbell spoke with Mr Samaan, took photographs and added his notes from the visit to a 'Food Incident Profile', which is an official record of a food borne illness complaint lodged with NSW Food Authority. Mr Campbell stayed at the home for about one hour and noted that the home was a small two bedroom housing commission unit, with a 'fairly small' kitchen, and a combined sitting and dining room.
115Mr Campbell asked Mr Samaan, "Do you have the leftover foods available from the home cooked chicken meal served to your family?" (transcript 2 August 2010, at 539). Mr Samaan answered that he did, and took Mr Campbell to the kitchen, where he then took from the freezer, a clear plastic bag containing what appeared to be frozen chicken. Mr Samaan said that this was the raw uncooked chicken that was leftover from the meal of Sunday, 23 October 2005 and Monday, 24 October 2005. The chicken was analysed and it was free from Salmonella. Mr Samaan spoke to Mr Campbell in English but there was no interpreter present, and stated that he may have answered 'yes' to a question he did not fully understand.
116Dr Givney commented on the inconsistencies in food histories in the following way (Advice of 8 April 2008 page 4):
"SUMMARY OF EPIDEMIOLOGY
I think it is apparent at this point that various investigators believe they were given information that seems inconsistent with Mr Samaan's Evidentiary Statement.
On the other hand, their epidemiological investigation processes were less than ideal.
There were difficulties with language but, nevertheless, there is no explicit mention in the Foodborne Illness Environmental Investigation Report (NSW Food Authority) ... that an interpreter was used to obtain the "Attachment A- Additional Epidemiological Details arising form the Authority's Interview with Case". The author of this Food Authority report also seems to accept uncorroborated advice from a 10 year old child about food the child had eaten 3 weeks previous.
There is an assumption throughout and stated explicitly in the Foodborne Illness Environmental Investigation Report (NSW Food Authority) ... that the absolute limit for the incubation of Salmonellosis is 72 hours and so no information should be sort earlier than 72 hours before onset. For reasons given in my previous advice, I think this unwise although very standard practice.
More generally the investigating Public Health Units seem to have decided somewhat prematurely and maintained on insufficient grounds that the home cooking was the cause of the infection. That, at least, is the impression given by the Foodborne Illness Environmental Investigation Report (NSW Food Authority) ... which states the public health units "conveyed to the Authority that the source was potentially from the family home cooked meal consisting of chicken, feta cheese or possibly sliced ham" and "dismissed" the KFC meal as "having any significance".
This view was apparently also conveyed to the Children's Hospital at Westmead whose Monthly Infectious Diseases Report No.170 ... states "A public health investigation concluded that undercooked chicken ingested 48 hours prior to the onset of illness was the most likely food source" which, of course, cannot refer to the KFC meal consumed the evening before the illness onsets. Interestingly this is the only mention in any of the documents of "undercooking".
The investigators noted only one other case of Salmonella Typhimurium 135a occurred outside the family at the same time outside the Samaan family and believed it was not related.
Interestingly there is contrary evidence in an OzFoodNet Report published in December 2005 and quoted in Foodborne Illness Environmental Investigation Report (NSW Food Authority)... Additional Epidemiological Details arising form the Authorities Interview with Case." Between August and December NSW had 54 cases of Salmonella Typhimurium 135a notified, an increase on previous years, but there is no indication that the people who investigated the Samaan cases were aware of this increase or attempted to make a connection. It is not clear if this is why NSW Health advised the NSW Food Authority to investigate KFC additionally i.e. whether NSW Health believed there was a potential for a source beyond a family's home cooking to explain increased numbers of cases across the state."
117The defendant has raised the contention that Dr Givney was instructed with a considerably less complex food history than has now been adduced in evidence. However, given the complexity in piecing together the history, this generally applies to each of the experts. I accept that Professor Fleet was perhaps provided with the most comprehensive overview. The complexity of the food histories given to the experts does not affect their opinions of the facts in issue upon which they were asked to comment.
118It is unfortunate, from the Court's perspective in being required to determine liability, that more emphasis was not placed on investigating KFC closer to the onset of illness as such an investigation would have been highly persuasive in inculpating or exonerating the Twister in this matter.
119Given the events occurring during the incubation period for the family's Salmonella poisoning, it is more likely than not that the unprepared chicken in the freezer was purchased at the same time as the chicken used in the schnitzel and was therefore part of the same batch of chicken the family ate over the weekend. This chicken was tested and it did not grow any of the bacteria that caused Monika's illness.