Penrose inquiry finds only limited fault with blood services

The state of scientific and medical knowledge in the 1970s and 1980s did not permit screening of blood amnd blood products for the hepatitis C and HIV viruses much earlier than it was carried out, according to the report of the Penrose inquiry, published today.

The six year inquiry, under Court of Session judge Lord Penrose, was tasked with investigating the cases of infection with these viruses that occurred in the 1970s and 1980s, through the treatment of National Health Service patients with contaminated blood and blood products. It concludes that 478 people acquired the hepatitis C virus from blood product therapy in Scotland, and 2,500 acquired the virus from blood transfusion in Scotland between 1970 and 1991; while 60 patients acquired HIV from therapy with blood products, and 18 from blood transfusion in Scotland.

In relation to HIV infection, the report concludes that "when actions in Scotland were subjected to international comparison, they held up well". It was only in 1984 that it became widely accepted that the HIV virus was the cause of Aids, and once this took place, "all that could reasonably be done, was done, in the areas of donor selection, heat treatment of blood products and screening of donated blood".

Regarding hepatitis C, which was finally identified in 1989, the report does however conclude that there was avoidable delay in introducing screening: an advisory committee decision to recommend screening could have been taken in May rather than November 1990, and there was then a further delay caused partly by the desire to begin from a uniform date across the UK, which was 1 September 1991. 

There is also some criticism that collecting blood from prisoners was not stopped earlier than it was (in 1984), though this is qualified by the comment: "Given the limitations in the information available at that time it is not clear, however, that earlier consideration would have stopped the practice."

One action the report believes should still be taken now is that the Scottish Government takes all reasonable steps to offer a hepatitis C test to everyone in Scotland who had a blood transfusion
before September 1991 and who has not been tested for hepatitis C.

The report recognises the strength of feeling that not enough was done to protect patients, and some campaigners were quick to accuse it of a "whitewash". 

Prime Minister David Cameron apologised to the victims on behalf of the British Government. Patients were affected in all parts of the UK, but only Scotland has held an inquiry. The contaminated blood scandal has been described as the worst treatment disaster in the history of the NHS.

Click here to access the report. The full report runs to 1,800 pages, but a chairman's statement and executive summary are also available.