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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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In December 1983, following discussions with Dr Savidge, Dr Winter decided to start using heat-treated concentrates (from Alpha) on a named patient basis.

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During December 1983, in relation to Dr Winter's decision to shift to using heat-treated concentrates (from Alpha) on a named patient basis. Dr Winter recalled Professor Bloom's reaction in saying that he was mad to switch as there will never be HIV in BPL Factor VIII.

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The heat-treated concentrates began to be available in May 1984 and from June 1984 the only concentrates being used were heat-treated Factor 8 and 9 both for hospital treatment and home treatment and prophylactically for children.

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When Dr Winter sent sera to Dr Tedder for testing in October 1984, all but one was positive for HIV. About half of those were children and some were people with moderate haemophilia.

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Dr Winter recalled Professor Bloom saying "You are mad to switch. There will never be HIV in BPL Factor VIII."

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Dr Mark Winter described it as "utterly bizarre" for doctors to discuss not providing results unless the patient asks for it.

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A group meeting with patients was held to discuss AIDS. According to Professor Christopher Ludlam's oral evidence, clinicians were still wrestling with the ethics of whether to inform patients about AIDS at this time, but decided to hold the meeting as the Yorkshire Post would publish a story within days.

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Professor Christopher Ludlum explained that he had been unaware of the recommendations issued by the Council of Europe to avoid using coagulation factors

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Professor Christopher Ludlam confirmed that his handwriting had been on a first draft of the AIDS Advisory document written by Professor Bloom in which Bloom had asked for comments from Ludlam stating that recipients had not been informed of receiving an infected batch.

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It was not until 19 December 1984 (by which time Professor Ludlam had known the results for 16 patients, as well as a larger number of negative results, for nearly two months but had not told a single patient) that a group meeting took place to alert patients to what had happened. It was not until 1985 that the process of informing individual patients of their test results commenced

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Professor Ludlam confirmed that he did not proactively raise the question of AIDS risks with patients, but stated that he would have answered questions if they were raised (although he could not remember such inquiries from patients).

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In oral evidence Professor Christopher Ludlum stated that he remembered not proactively informing patients of the risks of AIDS in taking concentrates around 1983/1984

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In oral evidence Professor Christopher Ludlum confirmed that he had become aware of AIDS in haemophilia patients in around August to October 1982

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In oral evidence Professor Christopher Ludlum emphasised that there was a lot of uncertainty at that time around AIDS and the cause of AIDS

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Professor Christopher Ludlum stated that at the time he had felt that the case of the San Francisco baby had been circumstantial evidence

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Professor Christopher Ludlum had stated that Dr Craske had been a virologist and therefore would see things from that perspective so he was not surprised that in a meeting Dr Craske had not noted any links for AIDS in haemophilia patients

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Professor Christopher Ludlum had stated that he had thought PFC concentrates had been reasonably safe and they had felt it reasonable to continue using cryoprecipitate

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