IT was a £12million public inquiry into the worst treatment disaster in the history of the NHS which was branded a "whitewash" by furious campaigners.

But the final report of the Penrose Inquiry into the contaminated blood scandal, which was published last week, contains shocking revelations buried in documentation and not yet reported in the press, about the events which led to nearly 3000 Scots becoming infected with hepatitis C and HIV in the 1970s and early 1980s.

With the five volumes of documents are revelations that blood donations were being collected from Scottish prisoners nearly a decade after international guidance advised against the practice.

There was a failure to introduce a policy on quizzing potential blood donors about intravenous drug use - despite a series of alerts being issued which said this population should be excluded due to concerns over a higher rate of hepatitis C.

Commercial blood products which led to children with haemophilia being infected with HIV were unlicensed at the time, the documents also show.

And routine screening of blood donations for hepatitis C was held up in Scotland because of funding issues which delayed it in England and Wales - which Scottish ministers were not informed about.

In his statement on the report, Lord Penrose made one just clear recommendation - everyone in Scotland who had a blood transfusion before September 1991 is to be offered a test for Hepatitis C.

Bill Wright, chair of Haemophilia Scotland, said the conclusions that Lord Penrose made were "not always entirely rational".

For example, he criticised Lord Penrose for making "value judgements" when concluding in some instances that standards in medical care were deemed acceptable at the time.

"The value judgement were being decided not by patients but by doctors," he said.

He added: "You could draw some parallels here in terms of people who got away with child abuse for a long time because it was all covered up."

Campaigner Bruce Norval, a haemophiliac who was infected with hepatitis C, said: "The content of the report and the actual summary and conclusions - they bear no relationship to each other.

"When you look at the contents of the report, it backs up everything that the campaigners have been saying."

A spokeswoman for the Penrose Inquiry said: "The Inquiry has fulfilled its responsibilities under the Inquiries Act (2005) and the Terms of Reference as agreed at the outset with Scottish Ministers."


Blood was collected from Scottish prisoners from at least 1957 and the Glasgow blood transfusion region was the last to cease collections on March 1984.

The inquiry concluded that it was "unfortunate" the Scottish National Blood Transfusion Service (SNBTS) did not consider stopping this practice until the 1980s, but adds: "Given the limitations in the information available at that time it is not clear, however, that earlier consideration would have stopped the practice".

However the evidence in the report highlights worrying examples of alerts being issued long before then. In 1976, the International Society of Blood Transfusion issued guidance which said prison inmates should be excluded from being blood donors, because they were at higher risk of having viruses like Hep C.

The inquiry report also notes that concerns about prison blood collection were being raised by the early 1980s and in June 1982, the Medicines Inspectorate questioned the collection of blood from prisons and detention centres in Scotland. But while the matter was discussed at a SNBTS directors meeting in March 1983, it was decided it was "not possible to agree a future policy". The report notes some regional directors - particularly in the West of Scotland - relied on prison blood collections to make up supply shortfalls.

Some countries never collected blood from prisoners - such as Denmark and Ireland. Others introduced a permanent or temporary deferral of blood collected from prisoners in the 1970s, including Switzerland and Finland. Others, including Portugal and Germany did not introduce such a move until the 1990s.


A total of 78 people contracted HIV from infected blood in Scotland - including 21 boys who were treated for haemophilia at the Royal Hospital for Sick Children in Glasgow. Most of the boys were thought to have been infected by commercially produced blood product, which were made from large pools of blood donations in the US.

The inquiry report concluded that other than by a general cessation of treatment with blood products known as concentrates, the infection of haemophilia patients with HIV from 1980 to 1984 could not have been prevented.

But campaigners point out that the inquiry found commercial blood products were unlicensed until 1983 and were therefore a matter of choice for doctors to make for their patient's needs. Haemophilia Scotland says it was the decision to import commercial clotting factor products - despite Scotland being able to produce sufficient domestic product - which led to an increase number of HIV infections.


The Inquiry report notes a series of alerts were issued from the mid 1970s on the issue of excluding certain high-risk populations from donating blood. In 1976, the International Society of Blood Transfusion (ISBT) issued guidance that intravenous drug addicts should be among those excluded from donating blood. Two years later, the blood transfusion service produced a document stating that "illicit drug taking if admitted or suspected should debar" - which was used as guidance by all Scottish regional transfusion committees.

But while some measures were implemented by the SNBTS - such as inspection, assessment and to a limited extent, interview, the report notes that until the advent of AIDS it seems likely "there was no uniform policy within the organisation in order to ensure that donors were routinely and directly questioned on their drug use".

Haemophilia Scotland says that direct questions about high risk behaviour should have been an integral part of the donor selection system.


In his statement, Lord Penrose noted a major area of concern among victims was the provision of information over issues such as the risks of treatments and results of tests. But he concluded the doctor-patient relationship had been "paternalistic". The statement also spoke of a "genuine lack of information as the understanding of the conditions developed" and doctors not "sharing all information available with patients".

The inquiry found there were no established procedures for communicating information about the risks associated with treatments.

It noted that the complaints of patients and their families about the lack of information highlights an important message for medical practitioners that patients infected with potentially fatal viruses are entitled to this information and should not have to wait while the medical profession "deliberates on general ethical issues."

Haemophilia Scotland says patients infected with hepatitis C or HIV should have been given the option to know their status immediately.


Routine screening of blood for the hepatitis C virus began across the UK in September 1991. But Haemophilia Scotland says a delay in introducing the screening was a "missed opportunity" to prevent infections.

The inquiry concluded that a decision by the Advisory Committee on the Virological Safety of Blood, to recommend the introduction of screening, should have been taken by the middle of May 1990 rather than in November 1990.

The inquiry documents reveal that subsequent delays in the start date were influenced largely by problems relating to the introduction of screening in England and Wales - such as funding. However Scottish Office ministers were not informed of this. There was "no scientific or medical grounds on which routine screening of blood donations in Scotland required to be started simultaneously with the rest of the UK", the inquiry report notes.

It added: "Consequently, Scottish patients lost, firstly, the benefit that would have accrued to them from the early introduction of screening and, secondly, the reduction in the risk of acquiring HCV by transfusion of unscreened, infected blood."