The Penrose Inquiry
CompletedPenrose Inquiry
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.
5 years, 11 months
Duration
£12m
Total Cost
Parliamentary Activity 4 Click to expand
4 questions
since Feb 2017
25 Nov 2021
08 Nov 2021
27 Feb 2017
27 Feb 2017
Reports (1) Click to expand
| Title | Volume | Publication Date | Tracked recs | Links |
|---|---|---|---|---|
| The Penrose Inquiry Final Report | Final | 25 Mar 2015 | 1 |
Timeline (3) Click to expand
01 Apr 2008
Inquiry Announced
01 Apr 2009
Inquiry Established
25 Mar 2015
Final Report Published
Recommendations (1)
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).
- 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)
View Details