Infected Blood Inquiry

– in the House of Commons at 5:48 pm on 2nd July 2018.

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Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office) 5:48 pm, 2nd July 2018

On 8 February 2018, I announced the appointment of Sir Brian Langstaff to chair the infected blood inquiry. From the outset, Sir Brian has been clear that he is determined to put people at the heart of the inquiry and to ensure an inclusive and transparent process.

Sir Brian and his team conducted a public consultation on the proposed terms of reference for the inquiry, which ran from 2 March to 26 April. They invited contributions via an online questionnaire, email, written correspondence and telephone. The inquiry team also held 15 meetings with groups and individuals across the UK, and Sir Brian is keen for the inquiry to continue to do that as it moves forward.

The inquiry received almost 700 responses to its consultation and Sir Brian, having reflected on those consultation responses, wrote to me on 7 June to advise me of the outcome and of his recommendations for the terms of reference. The terms of reference are comprehensive and reflect the key points made during the consultation.

The geographical scope of the inquiry is UK-wide. The inquiry will look at issues relating to the whole of the UK, as well as regionally. Sir Brian expects the inquiry team to hold regular meetings across the UK. I have therefore consulted, as I am required to do under the Inquiries Act 2005, with the devolved Administrations of Scotland and Wales and, in the absence of a Northern Ireland Executive, with my right hon. Friend the Secretary of State for Northern Ireland who, in turn, consulted the permanent secretary of the Northern Ireland Department of Health. The Governments of Scotland and Wales, and my right hon. Friend, were content with Sir Brian’s recommendations, and I am happy to accept his recommendations without amendment. I have written to Sir Brian to confirm this.

The terms of reference have been published and deposited in the Libraries of both Houses today. The inquiry can now formally begin its work; it will start today—2 July 2018. Sir Brian proposes to use groups of experts to assist the inquiry. Those groups would cover all the material fields relevant to the inquiry. Their evidence would be public, transparent and subject to scrutiny. People affected, and other participants to the inquiry, will be able to propose experts and put forward questions to the expert groups.

During the inquiry’s public consultation, views were expressed both for and against the appointment of additional panel members. Some, noting the complex and difficult issues to be examined by the inquiry, wanted a panel of many experts to assist the chair. It is Sir Brian’s view that his proposal for expert groups will achieve the objectives of those who have been in favour of panel members by providing legitimacy and transparency, a diverse range of expertise and, importantly, speed. Sir Brian’s view is that experts will be able to progress work in parallel in a way that co-determining panel members could not and that, very importantly, everything the expert groups will do will be public. Sir Brian plans now to discuss this proposed approach with those who will most centrally participate in the inquiry, particularly survivors and the groups representing them, and to ask them whether, in the light of the proposed approach, there remains any significant wish for him to be joined by a decision-making panel. Sir Brian has asked me to defer a decision on panel members until core participants have been appointed and have had the opportunity to consider the proposed approach.

I am aware that when my right hon. Friend Damian Green met people affected before Christmas last year, many supported the idea of the chair sitting alongside other panel members. I have not lost sight of that, but I think it is only right that I allow Sir Brian time to consult core participants. I therefore do not propose to appoint other panel members at this time, but I will consider the issue once core participants have had an opportunity to look at Sir Brian’s proposed approach. Of course, section 7 of the 2005 Act allows me to make further appointments to the inquiry panel during the course of the inquiry, with the consent of the chair. Speed is of the essence, and I have asked Sir Brian to report back to me as quickly as possible; I will then make my decision on panel members.

Many thousands of people from across the United Kingdom have been affected by this terrible tragedy. Sadly, a number of those affected have died since the inquiry was announced. One of the clearest messages from the inquiry’s consultation was the need for speed. In his letter to me, Sir Brian noted that one respondent to the consultation had said:

“I really hope this Inquiry does not drag on as I would like to live long enough to see the result”.

It is extremely important that the infected blood inquiry can complete its work as quickly as a thorough examination of the facts allows, and this is something that Sir Brian and his team are very aware of.

This inquiry is a priority for the Government, and I have assured Sir Brian that the Cabinet Office will provide all the resources and support that the inquiry needs to meet the demanding timescales that are essential in order to meet the expectations of people affected by this tragedy, who have already waited so long for answers. The inquiry will have much to do over the coming months, and I am sure it will waste no time in getting started. The first stages of the inquiry will be critical for obtaining evidence, including witness statements from people who have been infected and affected. The inquiry will use this evidence to help to uncover what happened and why. It will hold its preliminary hearings in September at Church House, London, where core participants will be able to set out their priorities for the inquiry. My exchange of correspondence with Sir Brian and the full terms of reference have been placed in the Libraries of both Houses, and I commend this statement to the House.

Photo of Chris Matheson Chris Matheson Shadow Minister (Cabinet Office) 5:55 pm, 2nd July 2018

I thank the Minister for his statement and for giving me advance sight of it.

Today’s statement is a sign of progress, but it is also an indicator of how delayed this whole process has been. It is a year since the inquiry was announced and six months since responsibility was, rightly, transferred to the Cabinet Office, yet we are only now getting details of its sittings and terms of reference. The unpleasant and inconvenient truth is that the longer the delays and the longer the grass into which this matter has been kicked, the fewer victims will be around to see justice done—the Minister referred to the testimony of one survivor in his statement. Taken together with other inquiries such as that on Grenfell Tower, where the Government had to chop and change the format numerous times in response to public dissatisfaction, we are given the overall impression that when it comes to public inquiries on public safety or government malfeasance, this Government have wanted to give away as little as possible, as late as possible.

Nevertheless, today we have seen progress. We welcome the statement, the new terms of reference and the start of the inquiry. It will look at issues ranging from what happened at the outset to the response of the Government, the treatment of victims and their families, the question of whether evidence was deliberately destroyed and a possible cover-up mounted, and whether individuals or institutions are to be held responsible. Those terms of reference have been welcomed by those affected, their families and the campaigners supporting them. May I also welcome the Minister’s recognition in his statement that speed is of the essence, given the previous delays?

We also welcome the fact that the inquiry is to be UK-wide, which will overcome the anomaly of previous inquiries or compensation schemes that were dependent on the jurisdiction in which the original contamination took place. We hope that the inquiry can now crack on with its work. Will the Minister confirm that it will be given the finance it needs to follow the evidence and complete its work so that it is unhindered and unrestrained by a lack of resources?

The responsibility in government for sponsoring this inquiry was transferred to the Cabinet Office because the Department of Health was at best conflicted and at worst possibly implicated, albeit perhaps historically. Will the Minister confirm that a clear instruction has gone out—or will go out—from Downing Street that full co-operation is expected from Ministers and officials at the Department of Health and Social Care? Have any mechanisms been put in place to support the inquiry by monitoring the Department’s co-operation in this matter?

We welcome the fact that Sir Brian Langstaff will have expert working groups to advise him. Some campaigners feel that the Penrose inquiry in Scotland suffered from having Lord Penrose sitting on his own, and we note that Sir Brian will make a recommendation to the Minister on additional panel members after consulting the core participants. There had previously been a doubt about the provision of legal aid to the victims and their families for the earlier consultation, so will the Minister confirm that support will be available for those participating in the inquiry itself—both financial support and, where necessary, counselling?

Will the Minister confirm that any claims to commercial confidentiality made by the firms involved or their modern-day successors will not take precedence over the need for the inquiry to get to the truth on behalf of victims? This inquiry now passes into the independent control of Sir Brian. However, will the Minister indicate whether there will be a mechanism for interim reports to be given to this House, and so to those affected and their families?

Finally, will the Minister join me in paying tribute to the courage, resilience and determination of the surviving affected people and their families who have stayed in this fight for so long? Will he also join me in paying tribute to hon. Members on both sides of the House in the all-party group on haemophilia and contaminated blood, and especially to my hon. Friend Diana Johnson for her leadership in keeping this matter in the minds of Ministers and the whole House?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

First, I welcome the hon. Gentleman’s support for the inquiry and for the direction of travel that I have announced today. I am happy to join him in paying particular tribute to the courage and tenacity of the survivors and the organisations that work with them. I also pay tribute to Diana Johnson and my hon. Friend Sir Peter Bottomley, who have worked together in a compelling demonstration of cross-party unity and determination to secure justice for the survivors.

On the time taken since the inquiry was announced, I emphasise to the House that the Government have tried consistently to move this inquiry ahead as quickly as possible. It was right that we reflected on the criticisms of the initial idea that the inquiry should sponsored by the Department of Health and Social Care, and that responsibility was therefore switched to the Cabinet Office. It was important to get a judge not only who had the right experience and expertise to take on the task, but who was willing to take it on and could free him or herself for up to two years, full time, to chair the inquiry. Finding the right judge with the willingness and ability to commit time is not always straightforward. Sir Brian has wasted no time: even ahead of his retirement from active duty on the bench in May, he took initial steps to understand the brief. Since his retirement, he has been active in ensuring that he talks directly to survivors’ groups and others. There is no doubt in my mind that he is absolutely committed not only to getting to the truth and securing justice, but to doing so in as speedy a way as possible, given the need to ensure the proper examination of evidence.

Let me turn to the hon. Gentleman’s particular questions. First, on finance, yes the Cabinet Office will provide Sir Brian and the inquiry team with all the resources that they need to do their job effectively.

Secondly, the Prime Minister has made it clear that the Department of Health and Social Care, the national health service and all branches of government should co-operate fully with Sir Brian and the inquiry. It is for the NHS in the devolved areas to take decisions in the light of the devolved Governments’ views, but I wish to make it clear that I have no reason to expect anything other than full co-operation. I know that the Governments in Scotland and Wales are determined to ensure that there is justice and openness and that, at the end of the day, the truth is delivered for survivors.

The hon. Gentleman asked whether measures will be taken to monitor the Department of Health and Social Care. I assure him that were there to be—I do not expect this—the slightest suggestion of a failure to co-operate, the necessary instructions would be given. The Prime Minister’s view on that has been absolutely clear.

The hon. Gentleman asked about legal aid, and I can confirm that we are making it available. We have said that people can claim for the costs of legal representation during the consultation. Under section 44 of the Inquiries Act 2005, I am allowed to determine the power of the chair to make awards for legal funding. Given the exceptional nature and gravity of the infected blood tragedy, I have decided that it is overwhelmingly in the public interest that the Government provide such funding for applicants. Those applicants will not be subject to means-testing.

The hon. Gentleman asked about the Penrose inquiry. One problem with that inquiry to which the Scottish campaign groups drew Sir Brian’s attention was that Penrose was assisted as chair by a single medical assessor. Sir Brian’s proposal is for there to be panels of experts representing different areas of expertise that need to be brought to bear in our search for the truth. He proposes that that is the best way, commensurate with the speed required, to ensure that the survivors get to the truth as rapidly as possible.

Photo of Philip Hollobone Philip Hollobone Conservative, Kettering

What is the Cabinet Office’s central working assumption about how long this inquiry will take and how much it will cost?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

Ultimately, such matters are for the chair of the inquiry, because the inquiry will be independent of Government direction once it has been established. Our working assumption is that it may take up to two years, but I do not want in any way to prejudge the decisions that Sir Brian will come to or where the evidence will take the inquiry.

Photo of Philippa Whitford Philippa Whitford Shadow SNP Spokesperson (Health and Social Care)

The infection of patients with hepatitis C and HIV from contaminated blood products is the worst tragedy and scandal in the NHS’s 70-year history in terms of the number of people infected, the ignoring of evidence, and the cover-ups on which we hope light will be brought to bear. As the Minister said, it is almost a year since the inquiry was announced, during which time, sadly, 90 people have died in England, Scotland and Wales and will therefore not get the answers for which they had hoped.

As the Minister mentioned, speed is of the essence, so what steps are the Government taking to avoid the end of the inquiry becoming entangled in a Maxwellisation process, as happened with the Iraq war inquiry? I am sure that the financial support available for legal counsel is welcome, but what financial support will there be to help victims and their families to attend the inquiry? I understand that it will move around the UK, but there will still be costs for families who are struggling.

Another limitation of the Penrose inquiry that was held in Scotland was that it was unable to force witnesses from the Department of Health to attend the inquiry, even though the scandal happened when that Department was responsible for healthcare right across the UK. The Minister referred to those who still work for the Government, but what about those who do not? Will the inquiry be able to summon witnesses and force them to give evidence? If the inquiry does not finally get to the bottom of what happened, the decisions that were made and the cover-up that may have happened afterwards, people will be very bitter.

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

I thank the hon. Lady for her support. She is right that there have been many allegations that there was not just an appalling degree of misjudgment and mistreatment of people, but then a subsequent cover-up. One of the specific terms of reference involves asking the inquiry to consider whether such concealment took place, who would have been responsible for it, and its extent, so that is very much something that Sir Brian and his team will look into. One problem with appointing co-determining assessors would be that that would almost inevitably slow down the speed at which the inquiry could progress, because we would need to find experts—there would be a question as to how many were required to cover the field—who were prepared to take off a year or two years, full time, to serve alongside the chair. That was one of the reasons that weighed heavily in Sir Brian’s mind when he made his proposals on the terms of reference.

On powers to summon people, yes, the 2005 Act gives an inquiry of this kind the power to compel the attendance of individuals.

Photo of Andrew Percy Andrew Percy Conservative, Brigg and Goole

In accepting Sir Brian’s view about the work of expert groups, can we be assured that those expert groups and panels will be fully transparent and that everything will be publicly available to those with an interest?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

Yes. In his letter to me, Sir Brian proposed that there should be expert groups covering a number of areas and expertise, and that those would range from clinical expertise, with that group itself needing to involve experts in haematology, hepatology and virology, and separate expert groups dealing with medical ethics, statistics, and the psycho-social impact of the infected blood scandal, to experts on public administration. It is certainly Sir Brian’s intention that the deliberative sessions of those expert groups should be undertaken in public, and that the core participants in the inquiry should be able both to propose to the chair names for appointment to those expert groups and to ask questions of the experts during their deliberative sessions as well as during formal evidence given by the expert groups to the inquiry in plenary session. Clearly, given the way that these inquiries normally operate, our expectation is that that intervention on behalf of survivors and other core participants would be via their legal representatives, and that again reinforces the reasons why the Government have agreed, exceptionally, to offer legal aid.

Photo of Diana R. Johnson Diana R. Johnson Labour, Kingston upon Hull North

I thank the Minister for making this oral statement today. The scale of the scandal is such that more than 2,500 people have already died as a result of this disaster. That is far more than all the other disasters from the 1970s added together, starting with the Moorgate tube disaster, running right through to Grenfell just last year—so more than all of those added up together. I want to pay tribute to all those who have fought, over many years, to get to this point. I am talking both about those who were infected and those who were affected. Madam Deputy Speaker, will you pass on my thanks to Mr Speaker for assisting Parliament in getting to this stage today by granting, I think, seven urgent questions, many debates, questions and statements in recent years, which has led to these terms of reference today? The terms of reference are comprehensive, covering many, if not all, of the points that those who were infected and those who are affected have raised with Sir Brian. The Minister made mention of two years as a possible timescale for this inquiry. Does he think that that is realistic considering that Penrose took far longer than that, and is there a mechanism by which Parliament can be given reports on a six-monthly basis of the progress that is being made?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

I join the hon. Lady in the tributes that she has paid to the campaigners. The two-year period is an estimate. It is very difficult to be more precise than that because so much depends on where the evidence leads Sir Brian and the inquiry team. The fact that the expert panels that he has proposed will be able to carry out their work in parallel with the inquiry proper will make it easier to progress at speed than was the case under Penrose where the medical experts sat as a co-determining member of the inquiry alongside Penrose himself.

I should have said in answer to Dr Whitford, but I am happy to say to Diana Johnson, that the inquiry will be able to offer interim reports. Although I cannot promise reports to the House at particular intervals, because, again, the inquiry is independent of Government direction, the possibility of interim reports is something that I have emphasised to Sir Brian and it lies within his powers.

Photo of Stephen Kerr Stephen Kerr Conservative, Stirling

I welcome the statement from my right hon. Friend. May I also say how important it is for my constituents and the families of those who have been impacted by this that the inquiry is conducted in a speedy fashion, with answers and conclusions available as soon as possible? Can he confirm that the lessons learned from the experience of the Scottish inquiry will be fully taken on board by Sir Brian?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

Yes, I can give that assurance. Indeed, when Sir Brian was consulting survivors’ groups and campaigners prior to sending me his proposed terms of reference, he took note from what was said by, among other groups, the Scottish Haemophilia Society and the Scottish Infected Blood Forum about what had gone wrong in respect of the Penrose model. Sir Brian is very keen to avoid those problems occurring in this new inquiry now.[This section has been corrected on 4 September 2018, column 1MC — read correction]

Photo of Frank Field Frank Field Chair, Work and Pensions Committee

On behalf of those families in Birkenhead who have been devastated by death and those who may face a similar fate, may I thank the right hon. Gentleman for his statement today? When the Prime Minister established the Hillsborough disaster inquiry, she broke the rules so that truth would emerge. She ruled, or got the whole Government to agree, that the onus was on Government to produce all the relevant papers and that the inquiry would not have to go fishing in the hope of finding those papers. Will he please give the same undertaking for this inquiry?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

I will happily give the right hon. Gentleman that undertaking. What is more, I know that my right hon. Friend the Secretary of State for Health and Social Care is utterly determined—

Photo of Frank Field Frank Field Chair, Work and Pensions Committee

Not only the Health Secretary’s Department but all the Departments involved.

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

My Cabinet colleagues are all very determined to get to the truth over this. It is important that the truth comes out both, and most importantly, to provide justice and transparency for the survivors and their families, and to ensure that any lessons about public administration can be learned and applied so that our constituents never have to go through such an experience again.

Photo of Huw Merriman Huw Merriman Conservative, Bexhill and Battle

On behalf of my constituents who have been affected by this most horrendous situation, may I welcome the update that the Secretary of State has given? With regard to their ability to be able to propose experts and to put forward questions to expert groups, how will that opportunity be cascaded so that no one misses out?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

It will be for the chair and his team to set out exactly how they plan to run the inquiry and how the expert groups, once appointed, will operate, but Sir Brian has demonstrated already his commitment to engage closely with survivors and campaign groups. I know that he will be very determined to ensure that nobody does inadvertently miss out on the opportunity to pose whatever questions they wish.

Photo of Alistair Carmichael Alistair Carmichael Liberal Democrat Chief Whip, Liberal Democrat Spokesperson (Northern Ireland)

On the question of additional panel members to sit alongside the chairman, the views of Sir Brian are obviously going to be very important and must be taken fully into account, but, ultimately, it will be the Minister’s decision, and it is a decision that will have a very profound impact on the job to be done. Expert advisers will give expert advice, but it will be the chairman and/or the panel members who ultimately make the recommendations. As the Minister decides whether or not to appoint extra panel members, can he assure me that the views of all those who have campaigned so long and so hard to get to this point will be taken into full account?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

I can definitely give the right hon. Gentleman that assurance. I shall be taking particular note when Sir Brian reports back to me in, I hope, a few weeks’ time of the views that have been expressed by campaigners and survivors’ groups in response to the proposals that he has tabled.

Photo of Eddie Hughes Eddie Hughes Conservative, Walsall North

A number of Members have commented on the importance of concluding this inquiry quickly, but will my right hon. Friend update us on the work that the chair of the inquiry has already done in preparing for the future stages?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

Sir Brian has carried out a number of meetings with groups and with individuals across the country. He and his team have conducted a public consultation online, inviting letters, emails and telephone calls. He has demonstrated his commitment to take this matter forward rapidly and to do so taking very careful account of the views of survivors in particular. When I met Sir Brian, it was very clear to me that his involvement in the Bristol Royal Infirmary public inquiry of a few years ago had made a huge impression on him, and I know that he wants to apply the lessons that were learned in that inquiry to deliver the very best possible inquiry into the infected blood scandal.

Photo of Catherine West Catherine West Labour, Hornsey and Wood Green

Will the Minister reassure me that in the overall inquiry survivors will be able to make their own representations independently of third sector groups such as the Haemophilia Society? That is not to detract from the organisation’s work in any way; it is simply that some individuals may not always have had a 100% positive relationship with such groups, and may want their representations to be considered completely separately from those of the society or other third sector groups.

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

In his letter proposing the terms of reference, Sir Brian Langstaff said to me that different groups had different views on how the inquiry should best be approached, and he will want to ensure that everybody gets their fair say. Obviously it is for the inquiry, not for Ministers, to determine who should be accepted as core participants.

Photo of Mike Wood Mike Wood Conservative, Dudley South

Will my right hon. Friend confirm that as well as direct legal expenses, related legal expenses in relation to responding to the consultation on the terms of reference will be met, so that the voice of victims and their families can be properly heard?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

Yes, all reasonable expenses for legal representation to respond to the consultation on the terms of reference will be met, and any individual claims will be handled by the solicitor to the inquiry.

Photo of Chris Stephens Chris Stephens Shadow SNP Spokesperson (Fair Work and Employment)

When this issue is raised, I always thank my constituent Cathy Young, a leading member of the Scottish Infected Blood Forum who lost her husband to contaminated blood.

I have had constituents who were involved in the Chilcot inquiry and waited years owing to Maxwellisation. This comes back to the question asked by my hon. Friend Dr Whitford. Will the Minister ensure that someone who is asked to be held to account or who is at fault for any reason will not unnecessarily delay the outcome of this inquiry due to Maxwellisation?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

It is in no one’s interests that this inquiry is delayed unnecessarily. It should take only as long as is required to establish the truth and come to appropriate conclusions. I believe that Sir Brian has the powers he needs to take forward an inquiry that is both thorough and speedy, and I very much trust him and his team to do that. He, as much as anybody else, is conscious of the agony that survivors and their families have already had to endure. He will not want the inquiry to last one day longer than is essential.

Photo of Stephen Kinnock Stephen Kinnock Labour, Aberavon

The Farrugia family in my Aberavon constituency have been treated in an absolutely appalling manner throughout this entire sorry affair, so they will certainly welcome today’s announcement. Will the Minister provide a bit more assurance about the access to the updates—regular and detailed ones, I hope—that my constituents will receive as this process begins and goes on?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

The question of whether there will be formal interim reports is a matter for the inquiry chair under the terms of the 2005 Act, but I can assure the Farrugia family, through the hon. Gentleman, that all proceedings of the inquiry and the expert groups will be public. I am sure that Sir Brian will want to ensure that the records of those proceedings are made widely available to all who are particularly affected.

Photo of Jim Shannon Jim Shannon Shadow DUP Spokesperson (Human Rights), Shadow DUP Spokesperson (Health)

I thank the Minister for his thorough replies to all Members. May I ask him, on behalf of my constituents—indeed, on behalf of all those across Northern Ireland, as a Member of Parliament for Northern Ireland—what plans the Government have to improve the financial support for people infected by contaminated blood and blood products, and their families? Also, what discussions has he had with the Northern Ireland Department of Health in the absence of a non-functioning Northern Ireland Assembly?

Photo of David Lidington David Lidington Chancellor of the Duchy of Lancaster, Minister of State (Cabinet Office)

Clearly it is for the health service in Northern Ireland to improve procedures, as the health service has sought to do throughout the United Kingdom in the light of what is already known about the contaminated blood scandal. One of the advantages of having the proceedings of the inquiry in public—including those of expert panels—and having the possibility of interim reports is that it would enable the health service in Northern Ireland and elsewhere to make whatever additional changes might be needed in the light of the inquiry’s emerging findings.