Penrose Inquiry (Hepatitis C)

Terms 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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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

12. To report as soon as practicable.

Chair: Lord Penrose

Dates:

· Establishment: 23 April 2008

· Hearings: Ongoing

Report:

Not yet reported

Link to website and or download report:

http://www.penroseinquiry.org.uk/

Description of the events which caused the public concern:

The infection of people with Hepatitis C in NHS treatment in Scotland.

Summary of reports recommendations:

Not yet reported

Any follow up bodies:

Not applicable