Penrose (Scotland)

The **Penrose Inquiry** was a public inquiry established by the Scottish Government under the **Inquiries Act 2005** to investigate the infection of people with **hepatitis C (HCV) and HIV** from NHS treatment with blood and blood products in Scotland. The inquiry was chaired by **Lord Penrose** and was formally announced on **April 23, 2008** by Nicola Sturgeon, who was the Cabinet Secretary for Health and Wellbeing at the time.

The inquiry focused on infections that occurred before the introduction of screening for these viruses in donated blood in 1991. It aimed to determine how these infections happened and to make recommendations to prevent such incidents in the future. The final report was published on **March 25, 2015**.

The inquiry examined the circumstances under which people were infected with HCV and HIV through NHS treatment, particularly focusing on the period from **January 1, 1974** to **December 31, 1991**. The inquiry investigated the deaths of five individuals: Reverend David Black, Mrs Eileen O'Hara, Alexander Black Laing, Neil Mullen, and Victor Tamburrini. These cases were specifically examined to understand the impact of the infections on their health and the subsequent response by the NHS.

One of the key findings of the inquiry was the lack of adequate screening and testing of blood products before 1991, which led to the widespread transmission of HCV and HIV among patients receiving treatment. The inquiry highlighted systemic failures in the management and oversight of blood products, including poor communication and coordination between different departments and agencies.

The final report made **one main recommendation**: to offer blood tests to anyone in Scotland who had a blood transfusion before 1991 and who has not already been tested for hepatitis C. This recommendation aimed to identify and provide appropriate care to those who may have been infected but were unaware of their status.

The Penrose Inquiry lasted for **72 months** (6 years) and cost **£12,123,754**. The inquiry's findings underscored the importance of robust infection control measures and the need for transparency and accountability in healthcare systems.

In summary, the Penrose Inquiry investigated the infection of people with hepatitis C and HIV from NHS treatment with blood and blood products in Scotland, identifying systemic failures and recommending blood tests for those potentially affected.