S3W-28916: Penrose Inquiry

To ask the Scottish Executive whether the Cabinet Secretary for Health and Wellbeing has considered the inclusion of additional deaths to be investigated by the Penrose Inquiry.

Answered by Nicola Sturgeon (13/11/2009): I have invited Lord Penrose to consider three additional deaths through the Penrose Inquiry.

I announced the terms of reference of the Penrose Inquiry in January 2009 to investigate the circumstances in which hepatitis C/HIV infection were acquired from NHS treatment with blood and blood products prior to the introduction of a test for hepatitis C in 1991. The terms of reference provided for two deaths, those of the Reverend David Black and Mrs Eileen O''Hara, to be investigated by the inquiry.

Three further deaths will now be considered by the Penrose Inquiry, those of Alexander Black Laing, Neil Mullen and Victor Tamburrini.

The revised terms of reference of the Inquiry will be:

Term of Reference 1:

To investigate the systems in place in Scotland for the collection, treatment, licensing, testing, preparation for supply and supply for use by the NHS of blood and blood products with particular reference to the risks of transmission of the hepatitis C virus and HIV to patients treated by the NHS in Scotland, including the role of government in regulation and setting guidelines and standards.

Term of Reference 2:

To investigate the systems in place for informing patients treated by the NHS in Scotland of the risks associated with the use in their treatment of blood or blood products, with particular reference to the risks of infection with the hepatitis C virus and HIV.

Term of Reference 3:

To investigate the systems in place in Scotland for obtaining consent from, and testing for infection with hepatitis C and HIV, patients treated with blood or blood products, and informing any patients found to be so infected.

Term of Reference 4:

To investigate the systems for recording and monitoring the numbers of NHS patients in Scotland treated with blood and blood products, with particular reference to the numbers exposed to risk of infection with the hepatitis C virus and HIV and the numbers contracting either or both such infections as a consequence of such treatment.

Term of Reference 5:

To examine the circumstances generally in which patients treated by the NHS in Scotland became infected with hepatitis C, HIV, or both through the use of blood or blood products in the course of their treatment, taking account of the development of scientific and clinical understanding and evidence internationally.

Term of Reference 6 (as revised):

To investigate the deaths of Reverend David Black, Mrs Eileen O''Hara, Alexander Black Laing, Neil Mullen and Victor Tamburrini, with particular reference to the circumstances in which they became infected with the hepatitis C virus, HIV or both.

Term of Reference 7:

To investigate the steps taken by those involved in, and those responsible for, the NHS in Scotland, including NHS boards and the Scottish National Blood Transfusion Service (SNBTS), their officers and employees and associated agencies, once hepatitis C and HIV were identified, to trace individuals who might have become infected with one or both of them as a result of receiving blood or blood products, and to identify any other or further steps that might reasonably have been taken to trace such individuals.

Term of Reference 8:

To investigate the steps taken by those involved in, and those responsible for, the NHS in Scotland including NHS boards and SNBTS, their officers and employees and associated agencies, to prevent the provision of infected blood and blood products.

Term of Reference 9:

To investigate the steps taken by those involved in, and those responsible for, the NHS in Scotland including NHS boards and the SNBTS, their officers, employees and associated agencies to inform individuals who might have received infected blood or blood products of the risks associated with their treatment for themselves and their families, and to offer treatment to any individual at risk, and to identify any other or further steps that might reasonably have been taken to inform and to treat such individuals.

Term of Reference 10:

To examine any particular adverse consequences for patients treated by the NHS in Scotland and their families of infection through blood and blood products with hepatitis C and HIV, including the treatment offered.

Term of Reference 11:

To identify any lessons and implications for the future, and make recommendations.

Term of Reference 12:

To report as soon as practicable.