Below are the submissions on the terms of reference made by Collins Solicitors on behalf of the campaign groups and individuals which we represent. These were lodged with Infected Blood Inquiry on 26th April 2018.

1. To investigate and consider all relevant issues on a timeline from inception of the National Health Service in 1948 to the present day;

2. Why England and Wales failed to achieve self-sufficiency in the production of Blood Products by 1977 as promised by Lord Owen in 1973, the then Minister of State for Health and Social Security;

3. The adequacy of the criteria, standards and procedures applied at all material times by all relevant Public bodies, their predecessors and any other relevant parties to protect haemophiliacs and others whether directly and/or indirectly from exposure to Contaminated Blood and/or Blood Products;

4. The adequacy and the timeliness of all relevant Public bodies, their predecessors and any other relevant parties at all material times in providing all relevant information of the risk of infection whether directly and/or indirectly to haemophiliacs and other relevant persons from Contaminated Blood and/or Blood Products (having regard to the development of scientific and clinical understanding and evidence internationally);

5. The adequacy of the criteria, standards and procedures applied to donor selection, screening and testing by Public and private bodies and other relevant parties at all material times, (having regard to the development of scientific and clinical understanding and evidence internationally) and all other relevant circumstances including but not limited to the delay in adopting relevant tests compared with other countries;

6. The adequacy of criteria, standards and procedures applied by Public and private bodies and other relevant parties at all material times to plasma quarantine, virus inactivation and product recall procedures at all material times (having regard to the development of scientific and clinical understanding) and evidence internationally and all other relevant circumstances;

7. The extent of any commercial or other interests including (without prejudice to the generality of the foregoing) the interests of pharmaceutical companies, the Haemophilia Society, individual Hospital Trusts, Clinicians, UKHCDO and others which may have affected the decision making process of the Department of Health, its predecessors and other relevant parties at all material times;

8. The extent to which any Contaminated Blood and/or Blood Products caused or probably caused infection and whether and to what extent the Department of Health, its predecessors and other relevant parties exercised their functions in relation to the inspection, distribution and use of such Contaminated Blood and/or Blood Products adequately and properly, and whether those functions were appropriate (having regard to the development of scientific and clinical understanding and evidence internationally) and any other relevant circumstances;

9. The procedures put in place at all material times, to carry out all relevant tests on haemophiliacs and others including but not limited to:

• Whether and to what extent all necessary informed consents were obtained;
• Whether and to what extent parents were advised that children were being tested and the parents’ informed consents obtained;
  The way in which the results of tests were communicated; and
• The extent to which a cohesive testing programme or programmes was/were adopted and if so whether this involved the involuntary and uninformed use of haemophiliacs and others, particularly mild haemophiliacs, children, spouses, partners and widows, as guinea pigs otherwise known as Previously Untreated Patients (PUPS);

10. The adequacy of medical and other treatments provided to haemophiliacs and others following infection;

11. The treatment of families after bereavement including but not limited to the extent to which adequate and appropriate care, psychological support and financial support, was provided, the response of Public bodies and others and the adequacy of that response.

12. The individual experiences of haemophiliacs and others and in particular the impact on families and others including but not limited to:

• Stigma/discrimination
• Advice received from Clinicians and others to conceal the true nature of any diagnosis made and/or the cause of death;
• Partners, widows or daughters of those infected, who for example may have chosen not to have children, terminated pregnancies, undergo sterilisation, undergo complex, expensive and often unsuccessful IVF treatment including sperm washing;
• Monitoring of transmission of HIV and other viruses from haemophiliacs to their sexual partners;
• Spouses/partners infected through sexual contact;
• The effects on children including the mental health of those infected, the impact on their siblings, the stigmatisation of a parent being infected and impact on children on losing close family members;
• Incorrect administration of Factor VIII to non haemophiliac patients;

13. The provision of residential and other educational facilities and the adequacy and appropriateness of relevant treatments, tests and investigations undertaken at or by those schools from time to time;

14. The adequacy of the response of the Haemophilia Society from time to time to the developing situation in relation to the issues associated with Contaminated Blood Products;

15. The actions of the various Trusts set up from time to time to distribute ex gratia payments including but not limited to

• The management of the Trusts and make up of the Boards;
• The adequacy of support provided;
• The provision of loans, the requirement of security and its subsequent enforcement;
• Discretionary payment of grants;
• The role of Central Government, particularly the Department of Health and the Department of Work and Pensions, in dealing with ex gratia Trust payments;

16. The adequacy of the Central Government’s response, financial and otherwise, to those infected as a result of receiving Contaminated Blood and Blood Products;

17. The financial repercussions including but not limited to an inability to secure:

• Mortgage finance
• Travel insurance
• Life assurance
• Pension provision
• Employment
• Immigration permission

18. The Defendants’ conduct in relation to and all the circumstances regarding the settlement of the 1991 litigation including but not limited to:

• the advice provided to the Defendants at the time regarding disclosure of documents;
• the circumstances under which the claimants were required to sign waivers;
• the Defendants’ requirement that the Plaintiffs provide waivers;
• the extent of the validity and enforceability of the waivers;
• the extent of and failure to inform of known risks;
• the issue of Crown and/or Public Interest Immunity

19. The role of Central Government and others in the provision of information to the media regarding the developing situation in relation to the viruses associated with Contaminated Blood and Blood Products;

20. All aspects of the conduct of the Department of Health, its predecessors and all other relevant Public bodies and persons at all material times and the adequacy and extent of any investigations (independent or otherwise) into their conduct, the adequacy and timeliness of any such investigations and the adequacy and timeliness of the provision of the results of any such investigations to haemophiliacs and others and the nature and extent of any harm caused by any delay, to include but not limited to the adequacy of the retention of documents policy by the Department of Health and other relevant bodies and the loss or destruction of medical records;

21. The nature and extent of any inaccuracies contained within medical records, medical reports, death certificates, Post Mortem reports and Coroners Conclusions and the extent to which this impacted on other issues including but not limited to the provision of information to the Trusts, DWP and the Office for National Statistics;

22. Whether the supervision by the Secretary of State for Health and/or his predecessors insofar as relevant to any of the above matters was adequate and appropriate having regard to the functions, responsibilities and duty of care of the said Secretary of State;

23. To identify all relevant areas of responsibility and apply criticism as appropriate; to report as soon as reasonably possible and make all appropriate recommendations (and interim recommendations where appropriate) following its findings on the relevant issues.—