Final Report

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How to Read the Final Report

Availability of the Final Report

The Final Report is published by the Inquiry in this printed version and on the Inquiry website

In 2010 Lord Penrose published a Preliminary Report which is available at

The printed version

The printed version of the Final Report consists of five volumes and an Executive Summary, which has also been printed as a separate document. There is also a DVD included in the box which holds these volumes as well as the Executive Summary, in both HTML and PDF versions.

The website version

The Final Report is available in HTML and PDF versions. It is fully searchable.

Structure of the Final Report

The Final Report consists of five volumes which represent five parts as set out in the contents page. The five parts cover: Patients' Experiences; Knowledge of HIV/AIDS and Hepatitis C; Blood and Blood Products; Donor Selection and Screening of Donated Blood; and Information to Patients.

The Executive Summary is printed as a separate document. There are conclusions within each chapter where appropriate. There is one recommendation which can be found at the end of Chapter 35, An Investigation into the Steps Taken to Identify the Individuals who were Infected (Look-back).


Footnotes in the Report include details of documents which provide the supporting evidence for points made in the text. The Inquiry assigned unique 10-character identifiers to every page in the evidence collected. These are in the form of three letters, followed by a three-digit number and a four-digit number, for example: SNB.002.1537. The reference for the document as a whole is simply the identifier of its first page. The three-letter prefix indicates the origin or nature of the document. 'SNB', for example, indicates a document from the archives of the SNBTS, and 'PEN' indicates a document or statement collected by the Inquiry during its own investigations. No significance attaches to this prefix in the context of the Final Report. In many cases the same document was recovered from several sources and the choice of which one to publish has been made on the basis of which was most complete or most readable.

In the electronic versions of the Report the document identifiers have been made into active links so that readers can click on the link and open the document to read the evidence for themselves.

Links are not included for some documents of a sensitive nature. These are generally the statements or medical records of patients and their family members. Some of the linked documents have also been redacted. This has been done to remove sensitive personal data or personal data that is not relevant to the Inquiry. The Inquiry's policy has been to leave as much text visible as possible so that the reader will understand the nature of the material that has been redacted.

The footnotes also contain references to the transcripts of the Inquiry's public hearings. These references give details of the witness, particularly where this may not be obvious from the text, the hearing day, and the page number or numbers where the relevant evidence appears. The transcripts are available on the Inquiry website and on the DVD attached to the printed version of the Report.

Reference period

The reference period for the Inquiry was 1 January 1974 to 1 September 1991. Some material necessarily pre- and post-dates this period in order to help fully understand the context in which events took place.

Names and designations

Each person mentioned in the Report is identified by his or her full name and title. Some of the people mentioned in the Report have had more than one designation during the reference period, a doctor, for example, becoming a professor. Their most recent title has generally been used in the text of the Report, except when quoting from contemporaneous documents.

The evidence given by patients and their relatives has been anonymised, except for the four named individuals whose deaths were investigated as part of the Terms of Reference: Reverend David Black, Mrs Eileen O'Hara, Mr Alexander Black Laing and Mr Victor Tamburrini. Those patients and relatives who gave oral evidence were given pseudonyms to protect their privacy.

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