2 February 2023: Closing Statements, Jamie Dawson KC (for most Scottish people) - B

Mr Dawson asserted that the assets and advantages enjoyed in Scotland should be considered for the particular level of culpability to be directed to the Scottish actors, as apart from those to be aimed at the UK level. The Scottish versions of administrative and eventually statutory devolution, mean that more could have been done locally to ensure the safety of patients, but it did not happen. Peter Foster was cited as someone who could have produced much more of a positive outcome, but he was not empowered to do so. Prof Cash was a formidable operator but too often he was relegated to the role of sniping commentator. It tended to be the individual and small groups of patients who led the advocating activity, but they were largely kept in the dark instead of being seen as an asset which could have made a real difference.

 

Scotland is relatively small, and people more readily know or have access to each other. Despite its size, there were considerable resources and centres of excellence such as medical schools, research facilities, and teaching hospitals. People had ready access to each other, but these connections were not used to spread important information. Mr Dawson listed a number of international connections and innovative developments, some of which became sadly missed opportunities. Even lowly Law Hospital was an innovative location, despite its prefab World War 2 built environment. Scotland could have been world-leading, but for various reasons the opportunities were not seized, rather they were buried before they were dead.

 

The independence of clinical actors was reflected as varying in the scale and nature of their independence and associated potential conflicts of interests. A number of conflicting clinical accounts were presented and Mr Dawson suggested to the Chair which of those culpable clinicians (like Profs Ludlum and Lowe) and those clinicians who were not running scared (like Prof Dillon and Dr Hann) should be given more attention and credibility. The excuses of not remembering, not knowing or not doing should be interpreted as them not wishing to say, not wanting to admit to knowing, or not acting when they should have.

 

The ”myth” of voluntary donation was the next theme. The domestic collection processes was not simply an altruistic volunteer act, it was not controlled, and the blood used was always local. While many donations were on the face of it “voluntary”, too many were not. The controls were not in place when they should have been (and many of these not despite but actually because of the social attitudes towards sex and drug use), and the local aspect was compromised due to examples such as obtaining blood from US military bases. Prisons were too easy a source, despite the extreme risks involved and the voluntary nature of their giving was at best questionable. Even job-site blood collections were not at all risk free, since people would not want to be identified as being part of a risk group which at times it was illegal to be part of, or socially still heavily stigmatised, such as engaging in homosexuals practices.

 

Processes to exclude higher-risk potential donors were insufficient and inconsistent. It was not just the clinical independence of haematologists that created problems, but also the autonomy of local collection centres. Leaflets were available but not universally adopted. Screening was not standardised and information sharing was haphazard. Too often the donors were seen as the patient by the blood collection bodies, above the blood recipient. The often-quoted text by Titmus had itself highlighted the nuances of what counted or did not count as voluntary donations. The decisions related to screening were similarly skewed. The possibility of screening results being wrong, and so impacting on donors, was given primacy over the known value of the screening processes to actually highlight viral infection in donated pints. The inspection systems were hampered in fulfilling their functions. This reduced the opportunities of flags to be raised and so infections not to happen and lives not to be lost.

 

There were unrelenting and irresistible pressures being exerted by haemophilia clinicians on blood collection bodies. Communications which looked like veiled threats highlighted the determination of clinicians to use concentrates. And if they could not obtain them locally, they would be obtained commercially with any blame for doing so being placed in the blood supply bodies. This was part of what Mr Dawson described as the “concentrate juggernaut”. Risks and alternatives were minimised in the drive to emphasise concentrates. The Scottish situation could have been different from the rest of the UK given the opportunities, but the drive to concentrates was relentless. The arguments for concentrates overplayed the convenience and underplayed the risks. Yet in some countries like Finland it was seen that the relatively small but certainly helpful benefits were far outweighed by the serious risks. Some had hoped for a way of mitigating the risks to come along, but surely this pointed to the need for a temporary pause in concentrate use until adequate safety was reached. The arguments about the harms which would happen if concentrates were held back were greatly over-emphasised. On a very small number of situations involving severe haemophiliacs would have required a concentrate-led regimen. For the vase majority of cases, cryoprecipitate would have been the preferable and sufficiently serviceable go-to treatment until safety thresholds were achieved. The concentrate production demands drove the blood collection focus. It actually required the reliance on risky donor sourcing.

 

The Yorkhill Hospital practices led to the death of 21 boys from AIDS. It was negligence without oversight. The Armour product was prepared specifically for children. Dr Willoughby ignored the risk literature and did not make himself available to explain his decisions. His juniors had insufficient knowledge, even of Non-A Non-B Hepatitis. The HIV infections should have been avoided. The lives shouldn’t have been lost. Had there been a more robust requirement to discuss treatments and risks, the very fact of the information being more available would have produced much greater opportunity for the tragedy to be avoided.

 

As with the Yorkhill case, the final submissions document contains a detailed consideration of the comparable situation of the “Edinburgh Cohort”. People were encouraged to seek that out for further information on such geographically specific concentrations of tragic cases. At this point just before the lunchbreak, Mr Dawson also pointed to the call for a recommendation related to a research fund being set up to investigate various aspects of viral infections arising from blood use. This type of investigation should have been initiated long ago, but still requires specific attention.