Final Report

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Appendix 2

Inquiry Organisation and Administration

The Inquiry Team

As Chairman of the Inquiry, Lord Penrose was independent of government or any other body or organisation. He alone was appointed to investigate the matters raised by the Terms of Reference.

Oliver James, Emeritus Professor of Medicine at the University of Newcastle, was appointed to act as the medical assessor to the Inquiry under section 11 of the 2005 Act. He was the principal adviser to the Inquiry on medical matters. He had 30 years' experience as a Consultant Physician and was a former Senior Vice President of the Royal College of Physicians (London).

Senior Counsel to the Inquiry was Laura Dunlop QC who was assisted by Euan Mackenzie, Nick Gardiner and Jane Patrick, Advocates. They did not represent any organisation or person appearing before the Inquiry. Their role was strictly impartial, assisting Lord Penrose to investigate the facts, examining witnesses at the hearings, providing advice on questions of law, evidence and procedure, liaising with Counsel for the Core Participants and assisting with the drafting of the Inquiry reports and other documents produced by the Inquiry.

Gillian Gibson (Galbraith), Advocate, assisted the Inquiry with the warning letters process and with the drafting of the Final Report.

The Solicitor to the Inquiry was Douglas Tullis assisted until June 2014 by Louyse McConnell-Trevillion, the Deputy Solicitor. They were responsible for the provision of legal advice, liaising with solicitors for the Core Participants, dealing with claims for expenses and drafting procedural documentation. Heike Gading and then Andrea Summers took on the role of Solicitor to the Inquiry after Douglas Tullis retired in December 2013.

The Secretary to the Inquiry was Maria McCann, assisted by Diane Barr and then Sarah Noble as Deputy Secretary. The Secretary was responsible for all administrative arrangements for example: commissioning an Inquiry office and hearings venue, the organisation of IT support, recruitment and management of paralegal and administrative staff, handling the Inquiry's finances, drawing up and implementing the Inquiry's communication strategy, including maintenance of the Inquiry's website. The Secretary and her team were also responsible for managing the publication of the Preliminary and Final Reports. The Documents and Evidence Manager was Neil MacFarlane assisted by Oliver Stempt and Keith Fleming. Neil and Keith also contributed to the drafting of the Final Report. At different times, members of the administrative team included: Fraser Paterson, Meg Orr, Kate Miguda, Sheila Renton, Rhona Carr, Samantha Doherty, Philip Brough, Lorna Gibson, Claire Stapley, Edin Omanovich, Kimberley Meikle, Kristina Hanson, Fiona McLean and Helen Fleming.

The Inquiry employed a number of paralegals, many of whom were, in fact, qualified lawyers. They developed expertise in particular subject areas of the Inquiry and used this expertise during different stages of the Inquiry, including to code documents and to assist Inquiry Counsel in preparing for and during the public hearings. Those who assisted the Inquiry as paralegals at various stages of the Inquiry were Angus Evans, Jenny Livingstone, Gemma Lovell, Stuart McWilliams, Gregor Mair, Janet Marsh, Jennifer Murphy, Teri Pidgeon, Lindsey Robertson, Charles Rogers, Yasmin Shepherd, Lorna Young and Laura Weir.

Sascha Cochran, Margaret Fraser and Jane Patrick were the statement takers responsible for taking the statements from patients and relatives. Margaret Fraser was appointed Witness Liaison Manager for the public hearings.

Mary Jane Bennett provided editing and proofreading services for the Preliminary Report and the Final Report. Murray Earle and Stefania Greci provided proofreading services for the Final Report.


The Inquiry leased office accommodation within the Scottish Legal Aid Board ('SLAB') premises at 44 Drumsheugh Gardens in Edinburgh. Due to the relocation of SLAB, on 29 September 2014 the Inquiry moved to Victoria Quay, Edinburgh.

The preliminary hearing on 31 March 2009 took place at Edinburgh International Conference Centre, The Exchange, Edinburgh. The public hearings were held at accommodation specifically leased for that purpose at Clydesdale Bank Plaza, 50 Lothian Road, Edinburgh. The procedural hearings on 10 October 2010 and on 29 October 2012 were held at the Apex International Hotel, 31-35 Grassmarket, Edinburgh.

Inquiry IT

The Inquiry's basic administrative IT systems were supplied by the Scottish Government as part of their SCOTSLite service, a service made available to smaller Scottish public bodies.

The Inquiry was very conscious from the outset that it could expect to receive a large quantity of documentary evidence. It was clear that IT systems would be required that were specifically designed for the handling and presentation of large numbers of documents.

Mike Taylor of i-Lit Ltd, an expert on IT for litigation and inquiries, provided advice on the selection of IT systems.

Tenders were invited through an Office of Government Commerce (OGC) framework agreement: Specialist Solutions - Electronic Document and Records Management Solutions. Framework Agreement Code A217837/L11.

The successful contractor was Computacenter (UK) Ltd. Working through a number of partners, Computacenter provided the Inquiry with a range of document processing services including initial processing, a document management system, and hearing room display systems.

Inquiry's website and bulletins

The Inquiry's website was launched on 10 February 2009. It was set up and maintained by Whitespace. It contained background information, key documents relating to the Inquiry, a witness timetable showing which witnesses were scheduled to give their evidence on a particular day, transcripts of the evidence heard at the public hearings, frequently asked questions and the preliminary report. It was updated regularly during the course of the Inquiry. This report is available on the Inquiry's website.

The Inquiry issued four bulletins during the course of the Inquiry to provide the public with a progress report and an insight into the work of the Inquiry Team.

Document storage

The Inquiry made use of Systematics Signature Delium database ('Signature database'). Over 118,000 documents were entered into this database. In addition to the material obtained from the Scottish Ministers, the SNBTS, the Department of Health and Lothian Health Board, over 1600 documents were collected in the course of the Inquiry including witness statements, documents provided by witnesses, medical records, scientific papers and journal articles. Assistance in configuring and managing the database was provided through the Computacenter contract by Elizabeth Miller and Alexander Parkes.

The initial processing of documents was carried out by Hobs Legal Docs in London. Services covered the scanning of paper files, the preparation of images and searchable versions of documents, and the inputting of various basic pieces of descriptive information for each document. In the event, most of the documents recovered by the Inquiry had already been scanned by the organisations providing them. This meant that there was little need to transport files to London for scanning, and Hobs were able to concentrate on the preparation of image files and descriptive data for loading into the Signature database.

It was clear to the Inquiry that the bulk of document recovery would occur in the early stages of the Inquiry and that there would need to be a system in place that could quickly assess documents for evidential significance. It was decided that there would be an initial coding exercise for these documents.

Once documents had been loaded into the Signature database the Inquiry Team undertook a subjective coding exercise to identify the issues that a document addressed and to assess the relative importance of the document.

Documents thought to be of interest were put through a second review undertaken by members of the Inquiry Team who had developed more detailed knowledge of the key issues during particular time periods. This review considered the importance level assigned to documents. Those documents which were still considered to be important after the second review were linked into the database's Chronology Manager which allowed a timeline to be developed. These documents were then passed to Inquiry Counsel.

It is important to note that documents not considered directly relevant at this stage remained in the Signature database and would still appear in search results. This ensured that documents whose significance might not have been obvious at an early stage of investigations would be available during more detailed investigation of particular topics.

As noted above, the subjective coding process was designed to deal with the initial receipt of large numbers of documents at the one time. Once these bulk deliveries had been completed, it was no longer considered necessary to formally have documents subjectively coded, as the smaller numbers of documents being received meant that they could be assessed for relevance directly. They were still looked at by Inquiry Counsel.

The main Signature database was only available to members of the Inquiry Team.

Public hearings: sharing documents

In preparation for the public hearings the Inquiry Team set up a separate version of the Signature database which would be available to the legal representatives of the Core Participants and which would also support the display of documents in the hearing room. Courtbook, as it was known, was initially set up with all the documents published with the Inquiry's Preliminary Report. Documents and witness statements for each of the topics to be examined during the public hearings were exported from the Signature database and imported to Courtbook so that the Core Participants' legal representatives could use them to prepare for hearings. Core Participants' legal representatives were also able to ask for documents to be added to Courtbook.

Documents were checked before copying them to Courtbook so that sensitive personal data could be redacted.

By the end of the Inquiry nearly 5000 documents had been placed into Courtbook.

The Inquiry Team provided training to Core Participants' legal representatives on the use of Courtbook and helped them to configure their IT systems to allow access to the database.

Hearing room systems

The specification for the hearing room systems was drawn up by Elizabeth Miller and the work of building and installing the systems was subcontracted by Computacenter to the NVT Group.

The server for the Courtbook database was installed in the hearing room premises throughout the period of public hearings. This was done to reduce the number of possible points of failure between the server and the hearing room when documents were being displayed.

Courtbook included tools for publishing documents as they were used in the hearings, and these tools were used to display Courtbook documents to Counsel, witnesses and the general public in the hearing room. The database allowed the Inquiry Team to record which documents had actually been exhibited and the witnesses with whom the documents had been used. At the end of each day's hearings any documents shown for the first time were exported from Courtbook and uploaded to the Inquiry's public website so that in due course they could be linked to the published transcript of the day's proceedings.

During the hearings, Counsel would read out the reference of any documents that they wished to show to a witness. The hearing room operater would call up the document on his PC and then publish it to monitors in front of the Chairman, the witness and the legal teams. Two large plasma screens were installed at the front of the public seating area so that members of the public could see the documents as they were being put to witnesses.

The hearing room network provided wired and Wi-Fi internet connections for the Inquiry Team and for Core Participants' legal representatives. Wi-Fi was also available for the press and the general public.

Hearing transcripts

A live transcription service was provided throughout the hearings by Merrill Legal Solutions. The stenographer was Catherine Anderson and the Editor was Stuart Marshall.

The Chairman and the legal teams were able to access the live transcript as it was created, allowing them to refer back quickly to earlier passages of evidence. The legal representatives could highlight or annotate sections of evidence for future reference. At the end of each day a corrected and checked version of the transcript was provided to the Inquiry Team, who then uploaded it to the Inquiry's website. The following day active links were added to the transcript on the website so that readers could open up any documents that were referred to during the hearing.

The transcripts of the evidence of those patient and relative witnesses who gave evidence anonymously were redacted prior to being uploaded onto the Inquiry's website. Each patient and relative approved the redactions made.

Video conferencing

Video conferencing facilities were set up in the hearing room to allow the Inquiry to take evidence from witnesses who would otherwise have found it difficult to take part. It also made it possible for a witness who was appearing in connection with more than one topic to give his or her evidence in separate video conferences to fit in with the logical order of the evidence rather than appearing in person for a whole day to deal with a range of topics.

Data protection

The Inquiry was registered under the Data Protection Act 1998.

Public relations

Media and public relations support was provided to the Inquiry by Golley Slater under a Scottish Government Marketing Services Framework agreement.


This report is published on behalf of the Inquiry by APS Group Scotland Ltd under the Scottish Government contract for supply of design, print, publishing and associated services.

Appendix 3: Core Participants >