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Dr Jones formed the view in the course of November 1984 that there should be a change to heat-treated Factor 8 and took steps to secure the regional health authority's agreement to that change.

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Dr Jones did not take steps to recall existing unheated product from patients: instead they were told to use up their present stocks and that the switch would be made when they came back for new supplies for their home therapy.

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Dr Jones had checked with representatives of the three companies (Armour, Cutter, and Alpha) supplying concentrates to the Centre who had all agreed to take back present stocks of non-heat-treated material without any financial consequences to the Health Authority.

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Terence McStay was the second patient to die of AIDS in the UK and a patient at the Newcastle Centre. He returned to his home in Glasgow shortly after he was diagnosed, and died on 3 November 1984.

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In the Daily Mail, it was reported that "Terence McStay went through seven months of hell before he died."

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In the Guardian, it was reported that Terence McStay had died after receiving a blood transfusion at Newcastle hospital.

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In a journal article in the Lancet, it was reported that "If the UK had been self-sufficient in factor concentrates, and these results had been replicated, generally they suggest that over 80% of the infections which occurred would have been spared".

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In Glasgow Royal Infirmary, the 77 patients whose blood was tested for HIV as part of a study were not told that these tests were taking place.

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Figures relating to the annual consumption of commercial factor concentrate at different haemophilia centres between 1976 and 1994. Also included are the factor types, product names, haemophilia type, number of units and volume amounts.

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At a Committee on Safety of Medicines Sub-Committee on Biological Products meeting, it was stated that the cause of AIDS was unknown. It was postulated that a new agent may have beeen responsible, but repeated exposure to, or reactivation of, known agents, (e.g. CMV, EBV) may have beeen involved.

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The UKHCDO recommended at the end of the 1983 meeting that patients did not switch from concentrates to cryo.

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Professor Franklin described in a letter how he and Professor Hill took the view that patients should have continuity in their factor product and given how erratic the NHS supply was it was better to keep them on commercial Factor VIII than switch between the two when NHS product was available.

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Dr Ala advised the West Midlands Working Party meeting - through letter - that cryoprecipitate was "probably a safer product than Factor VIII concentrate in respect of transmission of AIDS".

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The Working Party meeting did not result in any change of approach in regards to cryoprecipitate.

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The Queen Elizabeth Hospital return for 1983 showed some treatment with cryoprecipitate in hospital but predominantly treatment with NHS concentrate and Factorate in both hospital and home settings.

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The return for 1984 showed for the Queen Elizabeth Hospital that there was predominantly treatment with NHS concentrate and Factorate in both hospital and home settings.

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It was noted at Working Party meeting on the Treatment of Haemophiliacs that there was a shortfall of 3.5 million units of Factor 8 which it was agreed should be made up by commercial Factor 8.

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Professor Franklin wrote to Dr Lane registering his concern about the shortfall, which meant that the Centre might have to treat patients with commercial product who had never been exposed to it in the past.

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The West Midlands Working Party held an extraordinary meeting to discuss the implications of the use of Factor 8 concentrates in light of the death of two people with haemophilia from AIDS and a treatment policy was agreed

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Professor Bloom told the audience at a Haemophilia Society meeting that one of his patients "may have a mild form" of the syndrome.

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