Evidence

The hearing transcripts include links to images of all the documents referred to during the hearings.

Supplementary evidence

From time to time matters arise during the oral hearings which lead to the production of further evidence. These documents are listed below.

Latest additions -
21/05/2013 - Statistics - Information requested by the Inquiry following the Procedural Hearing on 29 October 2012
21/05/2013 - Topic B2 - The Inquiry made contact with Dr Willoughby and has obtained a statement from him

Name of witnessTopicDate of hearingDescription of requestDocument

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Mrs O'Hara

Day 3
Thursday 10/03/11

Transcript [PDF - 237Kb]
(pp139-40 and 147-48)

Letter of 25 August 2011 - from Dr Rachel Green to Tracey Turnbull, NHS Central Legal Office - In response to Chairman's request for further information concerning the inability to trace the relevant donors of the transfusions received by Mrs O'Hara due to the absence of Glasgow Royal Infirmary records, which could have enabled cross referencing to SNBTS pack numbers.

Letter, 25 August 2011, Dr Rachel Green to Tracey Turnbull [PDF - 75Kb]

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Mr Tamburrini

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After the conclusion of the hearings into the death of the late Mr Victor Tamburrini the Inquiry received four affidavits from Mr Tamburrini's family and friends.

Affidavit of Mrs Jean Tamburrini [PDF - 120Kb]

Affidavit of Mr Stephen Clocherty [PDF - 67Kb]

Affidavit of Mr Charlie Cunningham [PDF - 69Kb]

Affidavit of Mr Bernard Fisher [PDF - 88Kb]

Professor Goldberg

Statistics

Day 6
Wednesday 06/03/11

Transcript [PDF - 731Kb]
(p 141)

During Professor Goldberg's evidence Inquiry Counsel reported that the Skipton Fund had made 636 payments to people in Scotland. The Inquiry has recently been in contact with the Fund to establish the latest position. The Fund reports that payments have been made to 670 people in Scotland.

emails between Inquiry Team and Skipton Fund [PDF - 51Kb]

Professor Goldberg

Statistics

Day 89
Friday 30/03/2012

Transcript - 30 March 2012 [PDF - 257Kb]
(p 38)

During the closing hearing on 30 March 2012, Counsel to the Inquiry reported that work was continuing on the statistics topic. Further information on Hepatitis C infection through blood transfusion has now been received from Professor Goldberg and his colleagues.

In October 2011 Professor Goldberg and Dr Schnier produced a paper for the Inquiry, Estimation of the number of individuals infected as a consequence of blood transfusion in scotland 1970 - 1991

On 14 February 2012 the Inquiry Team wrote asking questions arising from that paper.

On 28 February 2012 Professor Goldberg responded to those questions and Professor Goldberg and Dr Schnier provided a supplementary paper Estimation of the number of individuals infected and alive in 2011 as a consequence of blood transfusion in Scotland 1970-1991

On 23 March 2012 the Inquiry Team wrote requesting further information from Professor Goldberg in the light of comments in a note by Professor James.

On 29 May 2012 Professor Goldberg responded to Professor James' comments.

Prof Goldberg and Dr Schnier's paper [PDF - 632Kb]

Inquiry's further questions for Prof Goldberg, 14/02/2012 [PDF - 117Kb]

Prof Goldberg's letter of 28/02/2012 [PDF - 158Kb]

Prof Goldberg and Dr Schnier's supplementary paper [PDF - 216Kb]

Inquiry's letter of 23/03/2012 [PDF - 90Kb]

Prof James' note [PDF - 64Kb]

Prof Goldberg's reply of 29/05/2012 [PDF - 148Kb]

Dr Hay

Statistics

Day 89
Friday 30/03/2012

Transcript - 30 March 2012 [PDF - 257Kb]
(p 38)

During the closing hearing on 30 March 2012, Counsel to the Inquiry reported that work was continuing on the statistics topic. Further information from the UK National Haemophilia Database has now been provided to the Inquiry

On 17 April 2012 Dr Hay of the UK Haemophilia Centres Doctors' Organisation wrote to the Inquiry Team with a report Bleeding disorder statistics for the Penrose Inquiry, from the UK National Haemophilia Database (2nd Edn.). This is a revised version of work that appeared as appendices to the Inquiry's Preliminary Report.

Prof Hay's letter of 17/04/2012 to the Inquiry [PDF - 86Kb]

UK National Haemophilia Database Report [PDF - 2Mb]

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Statistics

Procedural Hearing
Monday 29 October 2012

Transcript of Procedural Hearing - 29 October 2012 [PDF - 179Kb]

Lord Penrose's Written Decision

Lord Penrose Written Decision [PDF - 2Mb]

The Inquiry held a Procedural Hearing on Monday 29 October 2012 to consider a request that further oral evidence should be taken on the topic of Statistics. In his written decision following that hearing Lord Penrose concluded that there were issues on which it was appropriate to have further information, but that these matters could be dealt with in writing.

On 28 November 2012 the Inquiry Team wrote requesting information from Dr Gillon and Dr McClelland, from Dr Tait, from Dr Hay, and from Professor Ludlam

On 13 January 2013 Dr McClelland responded to the Inquiry's questions, and on 14 January 2013 Dr Gillon replied.

On 8 January 2013 Dr Tait replied.

On 16 January 2013 Dr Hay responded to the Inquiry's questions.

On 27 February 2013 a joint response was provided by Dr Hay and Professor Ludlam

Questions for Drs Gillon and McClelland 28/11/2012 [PDF - 69Kb]

Questions for Dr Tait 28/11/2012 [PDF - 79Kb]

Questions for Dr Hay 28/11/2012 [PDF - 79Kb]

Questions for Professor Ludlam 28/11/2012 [PDF - 77Kb]

Dr McClelland's reply of 13/01/2013 [PDF - 337Kb]

Dr Gillon's reply of 14/01/2013 [PDF - 241Kb]

Dr Tait's reply of 08/01/2013 [PDF - 234Kb]

Dr Hay's reply of 16/01/2013 [PDF - 178Kb]

Response from Dr Hay and Prof. Ludlam 27/02/2013 [PDF - 533Kb]

Professor Ludlam

B2

Day 18
Tuesday 10/05/11

Transcript [PDF - 798Kb]
(pp 133 and 136)

On Day 18 Professor Ludlam was asked about Professor Bloom’s letter of 04/05/83 to the members of the Haemophilia Society, and there was discussion of the information that Professor Bloom might have had available when writing that letter.

The Inquiry has now obtained a copy of the letter that Professor Bloom sent to haemophilia doctors in order to carry out his survey of the prevalence of AIDS in European haemophiliacs. This was issued on 05/12/83.

Professor Bloom's letter of 05/12/83 [PDF - 374Kb]

Dr McClelland

B2

Day 21
Friday 06/05/11

Transcript [PDF - 861Kb]
(p 109)

During his evidence Dr McClelland speculated that there might have been SHHD attendance at the meeting of the Biologicals Sub-Committee of the Committee on the Safety of Medicines held on 13 July 1983. The Scottish Government has investigated this and can find no evidence that any SHHD officials attended on that date.

Letter from Scottish Government to Inquiry [PDF - 63Kb]

Dr Foster

B2

Day 22
Tuesday 10/05/11

Transcript [PDF - 772Kb]
(pp 153-4)

Special application on behalf of SNBTS to allow an addendum to the SNBTS briefing paper Self-sufficiency and the supply of blood products [PDF - 5Mb] to be received in evidence.
Granted by Lord Penrose.

Addendum to SNBTS Briefing Paper [PDF - 500Kb]

Reference 1 [PDF - 4Mb]
Reference 2 [PDF - 1Mb]
Reference 3 [PDF - 26Kb]
Reference 4 [PDF - 658Kb]

Dr Boulton

B2

Day 24
Thursday 12/05/11

Transcript [PDF - 285Kb]
(p 46)

Dr McClelland's response to request from Inquiry team for clarification of point made by Dr Boulton about American visitors to Edinburgh who wished to give blood in 1982.

Request for information from Dr Brian McClelland [PDF - 33Kb]

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C1

Day 24
Thursday 12/05/11

Transcript [PDF - 885Kb]
(pp 176-177)

Inquiry Counsel undertook to investigate any reports by HM Inspector of Prisons (HMIP) about drug use among prisoners.
The Inquiry Team recovered various reports by the Secretary of State for Scotland and HMIP between 1975 and 1985. A note was produced setting out the main passages from these reports.
Inquiry Counsel prepared a note of the main questions which arose, and these were put to the Scottish Government.

Inquiry note - Extracts from reports [PDF - 215Kb]

Questions from Inquiry Counsel [PDF - 70Kb]

Response from Scottish Government [PDF - 155Kb]

Professor Cash

B2

Day 25
Friday 13/05/11

Transcript [PDF - 791Kb]
(p 94)

1991 correspondence from the BMJ concerning the Department of Health's 1990 definition of Self-Sufficiency. Referred to by Professor Cash at Page 94 of the transcript.

Letters in BMJ 1991, Self-sufficiency [PDF - 653Kb]

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B2

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In late 2012 the Inquiry was able to establish contact with Dr Willoughby, consultant in haematology at the Royal Hospital for Sick Children (Yorkhill) from 1963 to 1983. Dr Willoughby provided a brief statement to the Inquiry, followed by a second statement responding to questions from the Inquiry.

Dr Willoughby's initial statement [PDF - 109Kb]

Questions from the Inquiry Team [PDF - 162Kb]

Dr Willoughby's further statement [PDF - 208Kb]

Professor Leen

B6

Day 33
Wednesday 15/06/2011

Transcript [PDF - 805Kb]
(p 81)

At the end of Professor Leen's evidence it was agreed that the representatives of patients, relatives and the Haemophilia Society could put some further, written, questions to the witness if necessary. This was later done and responses were received from Professor Leen.

Professor Leen's responses [PDF - 14Kb]

Mrs Christina Leitch

B5 and B6

Day 38
Friday 24/06/11

Transcript [PDF - 822Kb]
(pp 140 and 155)

Special Application on behalf of Scottish Health Boards to allow supplementary comments from Professor Hann to be received in evidence.
Granted by Lord Penrose.

Prof. Hann's comments on Mrs Leitch's evidence [PDF - 63Kb]

Mrs Christina Leitch

B5 and B6

Day 38
Friday 24/06/11

Transcript [PDF - 822Kb]
(pp 140 and 155)

Special Application on behalf of Scottish Health Boards to allow supplementary comments from Dr Pettigrew to be received in evidence.
Granted by Lord Penrose.

Dr Pettigrew's comments on Mrs Leitch's evidence [PDF - 101Kb]

Professor Lowe

B5

Day 39
Tuesday 28/06/11

Transcript [PDF - 835Kb]

Day 40
Thursday 30/06/11

Transcript [PDF - 592Kb]

Special Application on behalf of Scottish Health Boards to allow an addendum to Professor Lowe's evidence on Topic B5 to be received in evidence.
Granted by Lord Penrose.

Addendum to Prof. Lowe's evidence [PDF - 89Kb]

Professor Lowe

B5

Day 40
Thursday 30/06/11

Transcript [PDF - 592Kb]
(pp 9 and 55-56)

Information about policies on pre-test counselling for HTLV-III and on testing for hepatitis at Glasgow Royal Infirmary.

Professor Lowe's response [PDF - 116Kb]

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B4 and C3

Day 51
Friday 30/09/11

Transcript [PDF - 432Kb]

Day 61
Thursday 3/11/11

Transcript [PDF - 849Kb]

Special application on behalf of the Scottish Ministers to allow additional statements from Alexander Murray and Hugh Morrison concerning the relationship between the Scottish Home and Health Department and the Common Services Agency to be received in evidence. Granted by Lord Penrose.

Mr Murray's additional statement [PDF - 466Kb]

Mr Morison's additional statement [PDF - 440Kb]

Professor Ludlam

C3a

Day 55
Friday 14/10/11

Transcript [PDF - 781Kb]
(p62)

Special application on behalf of Scottish Ministers to allow comment from Dr Iain Macdonald on the role of the Chief Medical Officer in giving guidance to be received in evidence.
Granted by Lord Penrose.

Dr Macdonald's comment [PDF - 120Kb]

Professor Ludlam

C3a

Day 55
Friday 14/10/11

Transcript [PDF - 781Kb]
(p 67)

Professor Ludlam was asked about the number of people first treated in Scotland with a blood product between 01/09/1985 and 30/06/1987. The Inquiry’s Preliminary Report (para 9.326) gave a figure of 31, based on the note of a meeting between Scottish Executive officials and haemophilia directors on 10/02/00. Note of meeting [PDF - 444Kb]

The Inquiry also has a copy of a letter from Dr Cachia to Dr Keel, dated 17/03/00, which gives a figure of 29 for the number of people first treated between 01/09/1985 and 31/12/1987.

Dr Cachia's letter of 17/03/00 [PDF - 72Kb]

Dr Smith

C3

Day 60
Wednesday 02/11/11

Transcript [PDF - 647Kb]

On 15/12/11 Dr Smith sent the Inquiry a supplementary statement to clarify aspects of his C3 evidence.

Dr Smith's Supplementary Statement [PDF - 248Kb]

Professor van Aken

C3

Day 62
Friday 04/11/11

Transcript [PDF - 489Kb]

Special application on behalf of SNBTS to allow an additional witness statement from Dr Peter Foster to be received in evidence, clarifying aspects of Professor van Aken's evidence.
Granted by Lord Penrose.

Dr Foster's additional statement [PDF - 131Kb]

Reference 1 [PDF - 540Kb]
Reference 2 [PDF - 381Kb]
Reference 3 [PDF - 633Kb]
Reference 4 [PDF - 283Kb]
Reference 5 [PDF - 563Kb]

Dr McClelland

C2

Day 63
Tuesday 15/11/2011

Transcript [PDF - 889Kb]

Day 64
Wednesday 16/11/2011

Transcript [PDF - 840Kb]

Following the conclusion of his evidence on Topic C2, Dr McClelland was asked to provide a further response to one of the questions he had been asked to address in his original statement.

Dr McClelland's supplementary statement [PDF - 78Kb]

Dr Forrester

C2

Day 66
Monday 21/11/11

Transcript [PDF - 827Kb]
(pp 26 and 30)

Special application on behalf of Scottish Ministers to allow an email from Dr Forrester to be received in evidence.
Granted by Lord Penrose.

Dr Forrester's email [PDF - 495Kb]

Professor Cash

C4

Day 82
Wednesday 11/01/2012

Transcript [PDF - 843Kb]
(pp 113-114)

The Inquiry asked Dr McClelland for any comments that he might have on Professor Cash's evidence.

Dr McClelland's supplementary statement [PDF - 54Kb]

Dr Mitchell

B2

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Dr Mitchell's response to questions posed to him on the B2 topic after the conclusion of B2 hearings.

Request for information from Dr Ruthven Mitchell [PDF - 225Kb]

Professor Ludlam

B6

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Special application on behalf of Scottish Health Boards to allow note of discussions regarding HIV Antibody Positive Haemophiliacs dated March 30 - April 13 1988 to be received in evidence.
Granted by Lord Penrose.

Professor Ludlam's notes [PDF - 189Kb]

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C1

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After the conclusion of hearings on Topic C1 the Inquiry received a document from the SNBTS dated 15/03/11 'Collection of Blood in Prisons'.

SNBTS report 'Collection of Blood in Prisons' [PDF - 4Mb]

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C1

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The Inquiry has taken a statement from Mrs Rosalind Prior, who worked for the SNBTS as a Mobile Team Assistant between 1969 and 1974.

Statement of Mrs Rosalind Prior [PDF - 157Kb]

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Details of membership of the Haemophilia Society's Medical Advisory Panel between 1983 and 1989.

Request from Inquiry [PDF - 37Kb]

Action by Haem. Soc. to identify Panel members [PDF - 181Kb]

List of Medical Advisory Panel members [PDF - 81Kb]

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Recovery of documents

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On 17 September 2009 Lord Penrose served a notice under section 21 of the Inquiries Act 2005 on Scottish Ministers requiring production of all documents in their custody or under their control relating to the Inquiry's Terms of Reference and dating from the period from 1 January 1974 to 31 December 2006. In response to that notice Ministers produced over 37,000 documents to the Inquiry. Two officials from the Scottish Government, Ben Plouviez and Nancy Woodhead, have been asked to provide written witness statements in relation to the procedures for the identification and production of those documents and to explain the position as regards documents that have been destroyed or are being withheld by reason of legal professional privilege.

Section 21 Notice [PDF - 221Kb]


Statement of Ben Plouviez [PDF - 698Kb]


Statement of Nancy Woodhead [PDF - 560Kb]

Annex A [PDF - 589Kb]
Annex B [PDF - 141Kb]
Annex C [PDF - 2Mb]

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Recovery of documents

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On 2 October 2009 Lord Penrose served a notice under section 21 of the Inquiries Act 2005 on the Common Services Agency for the Scottish Health Service requiring the production of 482 Scottish National Blood Transfusion Service files listed in the Appendix to the Notice. The 482 files in question were selected by Inquiry team from an index, referred to as "the documentation account", which had been prepared by SNBTS in anticipation of requests for production of documents from its records. In view of the importance of the documentation account in the identification of the files to be produced to the Inquiry a request was made to SNBTS for a witness statement on various issues arising in relation to its preparation. Such a statement has been provided by Neil Billing, the SNBTS Public Inquiry Team Co-ordinator.

Section 21 Notice [PDF - 97Kb]

Annex - Part 1 [PDF - 526Kb]
Annex - Part 2 [PDF - 582Kb]
Annex - Part 3 [PDF - 352Kb]
Annex - Part 4 [PDF - 224Kb]


Statement of Neil Billing [PDF - 135Kb]

Reference 1 [PDF - 101Kb]
Reference 2 [PDF - 53Kb]
Reference 3 [PDF - 59Kb]
Reference 4 [PDF - 69Kb]
Reference 5 [PDF - 74Kb]
Reference 6 [PDF - 79Kb]
Reference 7 [PDF - 157Kb]
Reference 8 [PDF - 698Kb]

Professor Ludlam

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Professor Ludlam has submitted comments to the Inquiry on Chapter 10 of the Preliminary Report.

The paper, Clinician's perspective on availability and use of clotting factor concentrates for treating haemophilia in Scotland in the context of Chapter 10 of the Penrose Inquiry Preliminary Report, is accompanied by various supporting documents.

Professor Ludlam's paper [PDF - 142Kb]


Letter from Dr Ludlam to Dr McClelland 10/05/1983 [PDF - 504Kb]

Letter from Dr McClelland to Dr Ludlam 30/12/1983 [PDF - 41Kb]

Letter from Dr Ludlam to Dr McClelland 11/01/1984 [PDF - 169Kb]

Letter from Dr McClelland to Dr Ludlam 15/05/1984 [PDF - 54Kb]

Letter from Dr Ludlam to Dr McClelland 23/05/1984 [PDF - 134Kb]

Letter from Dr McClelland to Dr Ludlam 26/11/1984 [PDF - 49Kb]

Letter from Dr Ludlam to Dr McClelland 30/11/1984 [PDF - 198Kb]


Fig. 1 Blood product distribution - East Scotland [PDF - 36Kb]

Fig. 2 Edinburgh monthly use of blood products [PDF - 365Kb]


Ref. 1 Eisa Hamouda Hamid MSc paper [PDF - 978Kb]

Ref. 2 Table - Commercial Human Factor VIII use [PDF - 43Kb]