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Lord Morris further described the effects of contamination by blood products as part of the worst treatment disaster in the history of the National Health Service.

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On announcing the Inquiry the Prime Minister, Teresa May, called the contaminated blood scandal "an appalling tragedy which should simply never have happened", highlighting that patients were failed by the NHS.

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In his oral evidence to the inquiry, Lord Horam acknowledged that he was repeatedly briefed by civil servants that people had received the best available treatment at the time.

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Lord Clarke suggested in his evidence to the Inquiry that the best treatment available line would have been a reflection of the fact that more people would be damaged, and the quality of life of people with haemophilia very badly damaged, if they were not provided with the Factor 8.

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In his oral evidence to the Inquiry, Lord Horam acknowledged that he was repeatedly briefed by civil servants that people had received the best available treatment at the time.

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In its written submission to the Archer Inquiry, the Haemophilia Society observed that without an independent review of its validity, no minister could be sure that the best treatment was given, and that the ministers' responses were complacent.

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In her witness statement to the Inquiry, Hazel Blears stated that the rationale for not setting up a compensation scheme for those with Hepatitis C was that there had been no fault on the part of the NHS, action had been taken to screen blood products as soon as the technology became available and there was no precedent for accepting liability without fault.

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In her oral evidence to the Inquiry, Dr Rowena Jecock described long standing lines as becoming embedded or hard wired into ones mindset, and accepted that there were occasions when there should have been more criticism.

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In his oral evidence to the Inquiry, Jeremy Hunt MP described a kind of memory illusion, but at a departmental level, where the people collectively tried to remember things as they would like them to have been, rather than as they actually were.

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In his oral evidence to the Inquiry, Andy Burnham stated the Government's response was primarily driven by a fear of financial exposure and that described all of the responses, lines and letters that came from this sentiment, and without thought to the needs of people who had their lives utterly ruined through no fault of their own.

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In his Reith Lectures "Unmasking Medicine" Professor Ian Kennedy observed that "it is a basic moral principle of our society that we should tell the truth".

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The expert group on Public Health and Administration highlighted the attributes of integrity, honesty, objectivity and impartiality formed the bedrock upon which the Civil Service was built; and this is as applicable to government ministers and officials as it is to clinicians.

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In her written statement to the Inquiry, Caroline Flint noted that her knowledge was incremental and that the policy briefing documents prepared by officials, while being very helpful, did not communicate the whole picture.

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In her written statement to the Inquiry, Deborah Webb referred to the drafting of statements and briefings being a collaborative process that followed the hierarchy of the team.

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In his oral evidence to the Inquiry, Alan Milburn said: "I think what happens is that some things do just get set in stone, history, which is malleable because it is subject to interpretation, it somehow or other at some point becomes set in stone and that may be for good reasons, maybe because actually the history is not contested. The problem here is that the history was contested."

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Concerns about the accuracy of the information contained in death certificates in England and Wales were raised by the British Medical Association.

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The British Medical Association was in favour of implementing the Brodick Committee's recommendation that doctors should certify the fact of death on a death certificate where they are unable to verify the cause of death.

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Andy Shanks advised ministers on further progress of the Penrose Inquiry and handling of additional deaths.

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Katrina Parkes, Head of the Scottish Fatalities Investigation Unit, responded to the Inquiry's request for records and information under Rule 9 of the Inquiry Rules 2006. It set out how in practice the Guidance for Doctors Completing Medical Certificates of the Cause of Death was implemented.

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HM Coroner in Birmingham and Solihull Districts wrote to Professor Alistair Geddes suggesting that Dr John Burton co-ordinates a policy now that Mr Justice Ognall's tribunal has been set up to ensure that coroner's treat these cases as Death by Natural Causes and no inquest is held.

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