Australia - Improper Design of Labels on Bottles of Plant Milk Led to Botulism Case

In Australia, a food company was fined when product was labeled with a improperly designed label that led to a case of botulism.  Bottles of almond and oat milk had labels that read '“once opened, keep refrigerated and consume within 5 days” and should have stated, "Keep Refrigerated".  A customer bought the plant-based milk and then stored it on the shelf in kitchen rather than the refrigerator, and after a person drank the improperly stored milk-type product, they became ill with botulism poisoning.  That person spent 147 days in the ICU as their bodies overcame the effects of the neurotoxin. 

“The incorrect content of the label was originally prepared for use on another, shelf-stable Ultra High Temperature (UHT) product offering, and was then inadvertently copied across to the new product packaging,” Judge Payne said.

The fine was $200,000..which seems pretty light for a botulism case by US standards.

This is a good reminder how important label design and approval is for the safety of the product.  Allergens are often the issue with label design, but in this case, safe handling instructions.

https://www.news.com.au/lifestyle/health/health-problems/honest-oversight-almond-milk-label-error-lands-man-in-icu-for-147-days/news-story/e5316c0db9882d26f1b0a94932bc6adb
‘Honest oversight’: Almond milk label error lands man in ICU for 147 days
A man's 188-day hospital nightmare has led to heavy penalties for a milk company whose labelling error caused one of Australia's rarest poisoning cases.
Sarah Keoghan
November 6, 2025 - 2:16PM

An Aussie milk brand has been ordered to pay almost $200,000 after a man fell ill from their almond milk and spent 147 days in the ICU.

Inside Out Nutritious Goods faced the NSW Supreme Court after they were found to have incorrectly labelled tens of thousands of bottles of almond and oat milk sold to Woolworths.

The milks required refrigeration below five degrees at all times; however, were labelled: “once opened, keep refrigerated and consume within 5 days”.

The company was charged by the regulator, the NSW Food Authority, after one man fell seriously ill after consuming the milk.

The court heard how Ms Karyn McGrigor purchased 10 bottles of the company’s 1L Unsweetened Almond Milk from Woolworths’ online store and stored them in the cupboard.

Ms McGrigor’s partner, Mr Mace, drank the milk and had to be hospitalised for 188 days from January 2023 to July 2023.

He spent 147 days in the Intensive Care Ward and received a formal diagnosis of botulism after the milk was tested.

Botulism is a serious condition which is caused by a toxin attacking the body’s nerves.

The condition can cause paralysis, vision, swallowing and breathing problems and can be fatal.

The court heard how there had only been three reported cases of botulism in adults in Australia between 1992 and 2019.

In his decision, NSW Supreme Court Judge Anthony Payne said that while the offending by Inside Out was an “honest oversight”, the potential harm caused by the incorrect labelling was “significant”.

Judge Payne detailed how the mislabelling was the result of “human error” and that the label was originally prepared for a different product.

“The incorrect content of the label was originally prepared for use on another, shelf-stable Ultra High Temperature (UHT) product offering, and was then inadvertently copied across to the new product packaging,” Judge Payne said.

“The error was not detected at the proof-reading stage by any officer of Inside Out.

“The packaging was put into production, the products were manufactured, and sent to the various Woolworths supermarkets for sale.”

Judge Payne ordered Inside Out to pay a $120,000 fine as well as $75,000 for the NSW Food Authority’s legal costs.

He said that general deterrence was “important” in the case.

“The penalty imposed must be of a sufficient size to deter other food manufacturing and distribution companies from similar offending,” he said.

“Protection of the public demands no less.”

In February 2023, Mr Mace’s botulism diagnosis sparked a statewide public health alert and recall of the products.