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Dr Diana Walford stated that "if somebody applied to the Medicines Division or the licensing authority, as they actually were deemed, for a clinical trial certificate or a clinical trial exemption certificate that was to be considered. It fell to be considered by Medicines Division, whether it needed to go entirely to a Committee on Safety of Medicines Meeting I think might have depended on the product."

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It appeared that there was no site examination at any of the blood collection centres in the USA.

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Dr Diana Walford recalled that upon visiting a USA manufacturing facility, the inspector and herself were very unhappy due to the lack of hygiene among other things.

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The Department of Health and Social Security was of the view that hepatitis was a serious disease and unless the intention was to process the plasma separately it would be impossible to prevent contamination of the UK material with imported hepatitis viruses.

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Dr Walford told the Inquiry that she felt not everyone at the DHSS was as aware that NANBH could give rise to chronic liver disease and this was why she had shared her comment with senior people

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In her evidence Dr Walford agreed that it was or should have been known to all those involved with BPL in the second half of the 1970s that the demand for blood products was rising, that it was or should have been obvious that BPL was outdated and too small, and that significant investment was required in order to be able to meet the rising demand, and that the Government had determined that BPL should meet standards equivalent to those expected of commercial plants.

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According to Dr Diana Walford's oral evidence, during her time at the Med SEB it was apparent that the transmission of non-A non-B hepatitis from blood products was a significant problem and had the potential to lead to chronic liver disease.

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According to Dr Diana Walford's oral evidence to the Inquiry, she wrote a minute to Mr Harley and spoke "quite forcibly" about the lack of awareness of the potential that Non-A, Non-B Hepatitis could cause severe chronic disease.

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According to Dr Diana Walford's oral evidence, the DHSS did not take any steps to ensure that clinicians, patients cohorts or representative bodies such as the Haemophilia Society were aware of the serious nature of Non-A, Non-B Hepatitis because the DHSS relied on clinicians as professionals to make themselves aware of issues.

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In her oral evidence, Dr Diana Walford indicated that on questions of treatment risks and benefits, the DHSS was guided by and deferred to the UKHCDO's views as it represented the group with relevant expertise.

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Dr Morag Chisholm protested to Dr Aronstam "many times" that she did not want concentrate used on patients, but was told it was needed.

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The parents of Gary Bennett, a Treloar's student, were not informed of the DDVAP trial.

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John Peach, parent of a student at Treloar's, was never told that his son was being given commercial concentrate.

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John Peach, parent of a student at Treloar's, was not told that prophylaxis was trialled on his son.

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John Peach, parent of a student at Treloar's, was not told as soon as his son developed hepatitis.

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Jason Peach, a student at Treloar's, was treated with commercial concentrate without his parents' knowledge and without them being informed of risk. The parents were only made aware of the possibility of their child going "yellow" with "a bit of jaundice", which they understood to be both mild and unavoidable.

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Nick Sainsbury remembered the Headmaster at Treloar's, Mr Macpherson, telling students not to worry hepatitis because they had the mild type.

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Jason Peach, a student at Treloar's, was never told by Treloar's school of his infections and instead he learned via his home centre, the Oxford Haemophilia Centre.

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Gary Bennett, a student at Treloar's, learnt of his infections from his home doctor, Dr Chisholm.

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The parents of Lee Stay, a pupil at Treloar's, were not involved with his treatment at the school.

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