In an inquest in 2012 into the death of one of the victims, the coroner stated that South West Water Authority had been "gambling with as many as 20,000 lives" when they failed to inform the public about the poisoning for 16 days, a delay he called unacceptable.
There were allegations of a cover-up and West Somerset Coroner Michael Rose stated: "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.
[11][12] In September 2013 the government admitted that there had been a "manifest failure to give prompt appropriate advice and information to affected consumers" and offered an unreserved apology.
One customer who telephoned the authority the day after the contamination was told "there had been some acidity, but the water was perfectly safe to drink," and was no more harmful than lemon juice.
"[19] Within two days, the authority suspected the source of the contamination was the erroneous delivery, which was confirmed on 12 July when the driver was asked to return to the treatment works.
However, it was not until ten days later on 22 July that the authority's chairman Keith Court authorised a public notice, containing the first mention of the aluminium sulphate, to be published in the sports section of a local newspaper, the Western Morning News.
[22][23] Douglas Cross, a consultant biologist based in Camelford, tested the water and found that it contained "not only aluminium sulphate but other noxious substances, too.
As the acidic liquid travelled from the plant into people's homes, it corroded the copper pipes and their soldered joints, made of zinc and lead.
[26] A month after the contamination, Michael Waring at the Department of Health (DH) wrote to every doctor in Cornwall saying that, "although he had no detailed information on what was exactly in the water or how much people might have drunk, he could assure them that no lasting ill effects would result.
[27] The National Union of Public Employees said that the procedure by which the driver had access to the site was common through the region and that they believed this was connected with reduced staffing levels and privatisation plans.
They added that they were concerned about the three-week delay in reporting what had happened, and that SWWA district manager John Lewis had been "instructed at a very high level to say nothing".
"[28] In August 1988 a highly critical report by Dr John Lawrence, a senior ICI scientist and non-executive member of the water authority, blamed lax procedures.
[36] The investigation was to be undertaken by the newly formed Lowermoor Subgroup (LSG) consisting of scientific and health experts and local resident representatives, chaired by Frank Woods, a professor of medicine at the University of Sheffield.
[36] Woods was also the head of the government's Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT), of which the Lowermoor team was a subgroup.
"[39] The following year, Meacher made several criticisms of the group: Two members of the LSG committee claimed in December 2007 that the DoH had known from the start that some people were at especially high risk from aluminium poisoning but deliberately suppressed this evidence to protect the government's plans for water privatisation.
Her death was caused by a form of early-onset beta amyloid angiopathy, a cerebro-vascular disease usually associated with Alzheimer's, which could be connected to the abnormally high level of aluminium in her brain.
[48][49] Michael Rose, the West Somerset Coroner, said of the findings: "Further research will be needed before the significance of the elevated brain aluminium concentration in this case can be clarified.
"[49] Daniel Perl, of New York's Mount Sinai School of Medicine said: "If additional similar cases were to appear among the 20,000 exposed individuals then the implications of this incident would become extremely important.
"[50] Rose had adjourned the inquests for Cross and Neal pending further studies, but in 2008 said the Government had refused "to either finance or assist" research to test the hypothesis of a link between exposure to aluminium and congophilic amyloid angiopathy.
The authority paid at least £123,000 to settle almost 500 initial compensation claims and in 1997 a further 148 victims accepted out-of-court damages totalling almost £400,000, approved by a High Court judge sitting in Truro.
[3] The judge, Mr Justice Wright, said: "If the case had been contested, there would have been awesomely complex argument over how much [water] they consumed" and that they were "extraordinarily well advised to accept the offer.
[citation needed] The Western Morning News, using a Freedom of Information Act request, uncovered a briefing note to the then Environment Minister, Nicholas Ridley, warning: "Those of the South West board with a commercial background are deeply concerned by the investigation.
"[3] In 2001 Environment Minister Michael Meacher claimed that the Government feared what an unrestricted inquiry might find, and that "There was then a great deal of shenanigans about the terms of reference and fighting at all levels in order to limit the ambit of the committee to get the result they wanted.