The Penrose Inquiry

Completed

Penrose Inquiry

Chair Lord Penrose Judge / Judiciary
Established 01 Apr 2009
Final Report 25 Mar 2015
Commissioned by Scottish Government

Scottish inquiry into infection of NHS patients with Hepatitis C and HIV from contaminated blood products. Made only one recommendation despite six years and £12m cost. Widely criticized as a "whitewash" by victims.

Evidence & Impact
The Penrose Inquiry was established in April 2009 to examine NHS Scotland's involvement in the use of infected blood and blood products, particularly relating to HIV and hepatitis C transmission through blood transfusions and blood products between 1970 and 1991. Lord Penrose published his final report on 25 March 2015.

The inquiry made a single recommendation: that the Scottish Government should take steps to offer testing for hepatitis C to anyone in Scotland who had a blood transfusion before September 1991 and who had not already been tested.

While no formal government response was published, the Scottish Government established a Short-Life Working Group with Health Protection Scotland and Scottish National Blood Transfusion Service to develop a testing programme. According to progress updates, this testing programme was established by December 2015.

The limited scope of the Penrose Inquiry's recommendations drew criticism from some affected individuals and campaigners who had hoped for broader findings on accountability and compensation. The progress update notes that the subsequent UK-wide Infected Blood Inquiry, which reported in 2024, made more comprehensive recommendations covering compensation schemes and systemic reforms.

The available evidence indicates that the single recommendation regarding hepatitis C testing was acted upon through the establishment of a testing programme. However, the broader issues of infected blood and blood products continued to be examined through the later UK-wide inquiry, which addressed matters beyond the narrow remit of the Penrose Inquiry.
Reforms Attributed to This Inquiry
- Testing programme for hepatitis C established by Health Protection Scotland and Scottish National Blood Transfusion Service following the inquiry's recommendation
AI-generated narrative. Generated 26 Mar 2026 using claude-opus-4. Assessment is indicative, not authoritative.
5 years, 11 months Duration
£12m Total Cost
Government Response

Total Recommendations 1
Data last updated: 31 Dec 2015 · Source
Data verified: 8 May 2026 (import)
How to read this

Government Response tracks what the government said it would do (accepted, rejected, etc.).

Full methodology

4 questions since Feb 2017
Written Question Equitable Life Assurance Society
Baroness Bowles of Berkhamsted (Liberal Democrat)
25 Nov 2021
Written Question Equitable Life Assurance Society
Baroness Bowles of Berkhamsted (Liberal Democrat)
08 Nov 2021
Written Question Blood: Contamination
Diana Johnson (Labour)
27 Feb 2017
Written Question Blood: Contamination
Diana Johnson (Labour)
27 Feb 2017
Title Volume Publication Date Tracked recs Links
The Penrose Inquiry Final Report Final 25 Mar 2015 1
01 Apr 2008
Inquiry Announced
01 Apr 2009
Inquiry Established
25 Mar 2015
Final Report Published

Recommendations (1)

PENROSE-1
Accepted
HCV Testing for Pre-1991 Transfusion Recipients
Recommendation

The Scottish Government takes all reasonable steps to offer an HCV test to everyone in Scotland who had a blood transfusion before September 1991 and who has not been tested for HCV.

Published evidence summary
- The Scottish Government established a Short-Life Working Group in 2015, comprising representatives from the Scottish Government, Scottish National Blood Transfusion Service, and Health Protection Scotland, to assess the feasibility of the recommended lookback exercise (Short-life working group progress report, Scottish Government, September 2016).
- The Working Group estimated that approximately 93,600 people who received blood transfusions before September 1991 were still alive in 2015, of whom approximately 100 had acquired HCV infections and roughly 32 remained undiagnosed — a ratio of approximately 1 in 3,000 among untested transfusion recipients (Short-life working group progress report, Scottish Government, September 2016).
- The Working Group assessed and rejected retrospective donor testing (estimated cost £8-10 million, 6-7+ years), record interrogation, population notification, and general screening as impractical or disproportionate given the small number of undiagnosed cases (Short-life working group progress report, Scottish Government, September 2016).
- The Working Group unanimously recommended three actions: a targeted awareness campaign for pre-1991 transfusion recipients, direct outreach to approximately 71 plasma product recipients not yet tested, and a Chief Medical Officer letter to clinicians highlighting HCV risk factors and treatment advances (Short-life working group progress report, Scottish Government, September 2016).
- In October 2016, the Scottish Government launched the awareness campaign, distributing approximately 400,000 posters and leaflets across GP surgeries, hospitals, care homes, pharmacies, and community buildings throughout Scotland, targeting people who received blood transfusions before September 1991 (Infected blood awareness, Scottish Government, October 2016).
- Health Protection Scotland analysis showed that in the three months following the Penrose Report's publication in March 2015, HCV testing referencing blood transfusion risk increased from 7 tests in 12 weeks before publication to approximately 400 tests in the same period — extrapolated to approximately 1,000 additional tests across Scotland (Short-life working group progress report, Scottish Government, September 2016).
- In May 2024, the First Minister made a statement in the Scottish Parliament apologising to victims of the infected blood scandal (Statement on infected blood, Scottish Government, May 2024).
Scottish Government (Primary)
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