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The Medical Ethics Expert Group, said that when harm befalls a person, there were, from an ethical perspective, three particularly important factors: (i) responsibility must be attributed; (ii) openness and transparency are needed; and (iii) recognition is required so that those responsible for the harm can understand its nature and the impact it will have had.

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Giving evidence as part of the Medical Ethics Expert Panel, Professor Farsides stated that "we won't learn the proper facts of the matter if people are being defensive or hiding things or even not taking it seriously enough to dig down and find the important information", with Professor Kerridge adding that "these same principles apply in areas of politics."

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Speaking about a cover-up, Mrs AJ, giving evidence, said: "If this had happened on one day, if a plane had dropped out of the sky killing everyone on board (only in this case it would have been six planes) or if a liner had hit an iceberg (in this case it would have been two liners), something would have been done immediately."

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Professor Savidge attributed the failures to effect self-sufficiency and eliminate viral contamination to poor leadership assuming safety of BPL products and a lack of political will to spearhead essential changes that were evident by 1978.

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In a letter, Clive Collins updated A Woodhead at the DHSS regarding the situation of a donor infected with HIV in the US with this infected batch being distributed to centres in the UK.

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A potentially infected Armour batch was not reported to the DHSS. The letter concerned the follow up of a potentially contaminated batch of Factorate before it was removed from the market

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In notes on an informal meeting with the DHSS, Clive Collins noted that the HTLV-3 viral inactivation studies needed to be repeated.

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Dr Alfred Prince, an eminent virologist, had conducted viral inactivation tests on Armour's product.

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Dr Prince reported in his findings after conducting viral inactivation tests on Armour's product that higher inactivation process efficacy could not be demonstrated in this experiment due to the unexpectedly low titer of the virus stock employed.

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In a letter, Armour had learned that a batch of heat-treated Factorate, to which a donor who had subsequently developed AIDS was known to have contributed, had been distributed to eight centres in the UK.

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Alpha Pharmaceuticals disclosed the results of tests which showed that their heating processes had inactivated HTLV-3/HIV virus load to a degree sufficient to show they were effectively safe. This information was published in a leaflet disclosed to patients.

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Armour was informed that a patient in Lewisham had seroconverted after receiving a dose from a heat treated batch and noted that "This patient is the first to show sero-conversion from HTLV-III negative to positive following administration of the batch of Factorate Heat Treated in question".

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Dr Peter Jones told a conference in Newcastle of suspected seroconversions of HIV after using the Armour produced Factor 8 in the Netherlands and the US.

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Dame Contreras told the Inquiry that with hindsight, testing could have started in July 1991 or earlier, once the second-generation tests were available.

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Dr Barbara told the Inquiry that with hindsight, he did not believe there was any reason (provided they received the RIBAs) why the testing of the second generation tests couldn't have occurred in parallel with the introduction of testing for all donations.

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Dr Boulton told the Inquiry that he felt there was an ethical need to introduce Hepatitis C screening at the earliest opportunity, and that it was shameful that "the UK was among the latest countries in Europe" to introduce testing.

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Dr Huw Lloyd's evidence to the Inquiry was that Dr Gunson never communicated to him that there was a funding reason holding up the commencement of screening.

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Dr Perry recalled that Dr Metters was concerned that all the details had to be correct before the bigger in principle decision could be made on HCV screening.

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Dr Rejman expected the PHLS would soon publish the results of their experience of Chiron testing of presumed non-A non-B Hepatitis samples, and would be making a recommendation for use of this test in this publication in September 1989.

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It was the preference, but not a formal requirement, that the test be licensed in the US by the FDA before being adopted for use in the UK.

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