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In oral evidence Dr Mark Winter described how in the 1980s, despite the growing concern of the hepatitis virus, treatment with factor concentrates continued unabated.

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With respect to the growing prevalence of AIDS and the response of UKHCDO, Dr Winter explained how the issue with blood products was that there were constantly new viruses being discovered.

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Dr Winter described how the San Francisco cases in 1982 led to the start of haemophilia doctors understanding they were dealing with a transmissible blood disease.

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Dr Winter described how there are two major problems with concentrate therapy. Firstly, liver disease was much more significant than they thought. Secondly, they required a lot more information to understand what the disease was, how to test for it and how to respond.

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Dr Winter stressed that all haemophilia clinicians were on alert by the end of 1982 on what was occurring regarding the AIDS epidemic.

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Dr Winter explained to the Penrose inquiry that around December 1982, all doctors would have had to interpret the reports from San Francisco that three patients had received blood infected with HIV, and so conclude that HIV was a transmissible disease through blood/blood products.

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Dr Winter held that by 1982, there should have been 'alarm bells' over the potential seriousness of the HIV virus.

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With regards to treatment taking place at Guy's Hospital and Margate, Dr Winter, who worked as one of the senior registrars held that there was never enough NHS commercial concentrate.

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Dr Winter held that due to the shortage taking place at Guy's Hospital and Margate, Tooting Bec hospital had to cover the shortage.

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Dr Winter held that due to the shortage Shortfalls were covered by the use of commercial concentrate, and cryoprecipitate was in limited use only for mild haemophilia or von Willebrand disorder, or occasionally for a child or rarely treated adult.

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With regards to treatment taking place at Guy's Hospital and Margate, Dr Winter held that patients diagnosed with moderate haemophilia may have also received commercial concentrates

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With regards to treatment taking place at Guy's Hospital and Margate, Dr Winter held that patients diagnosed with mild haemophilia may have also received commercial concentrates, in instances where DDAVP was proving ineffective.

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With regards to treatment taking place at Guy's Hospital and Margate, Dr Winter held that while children were prioritised for being treated with NHS products and that prophylactic treatment for children, there was a possibility that children received commercial concentrates too.

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With regards to treatment taking place at Guy's Hospital and Margate, Dr Winter held that with regards to the treatment of children, the general practice was that children were not given concentrate unless they absolutely needed it.

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Dr Winter took the post as director at the Haemophilia Centre in Margate in December 1983.

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Dr Winter held that at the Haemophilia Centre in Margate that around the time of 1983, there was a serious lack of funding.

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Dr Winter explained that no one approached Tooting hospital to help address the issue of cryoprecipitate supplies.

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Dr Winter held that both GPs and pharmacists did not have adequate knowledge as to the type or amount of Factor 8 being used for home treatment.

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Dr Winter held that there were inadequate records as to what treatment patients received

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Dr Winter held that at the Haemophilia Centre in Margate that around the time of 1983 that due to a lack of funding pharmacists would not have adequate access to NHS concentrate from RTC.

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