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QUESTION: The general public sessions would take place in village halls and community centres and the like; i s that correct? ANSWER: That was the usual arrangement, yes.
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QUESTION: Prior to the new centre opening in 1985, were blood donor sessions ever held in the old centre? ANSWER: I don't think so. I don't think there was a facili ty, 168 a room in the old Centre that would take it but, no , I don't recall it.
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QUESTION: Then once you had the new Centre, is it right that there were some blood donor sessions that together place in the new Centre but it wasn't a major part of the Centre's use? ANSWER: No, it wasn't. The drawing has been shown as a don or facility, a donor room was given over to plasmapheresis, so we allowed -- I say allowed -- w e accepted occasional walk-in donors who just thought : well, here's the Transfusion Centre, I'll donate blood. We would take their donations in the plasmapheresis unit. But we did hold some, sort of, full-blown sessions by clearing out the dining room and using that as a site, and we'd bring up a set of beds tha t would normally be used on a mobile session and we'd set up almost as though it was a mobile facility th at happens to be in our building.
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QUESTION: In terms of the geographical reach of the donor sessions, is it right that the sessions took place all over the area but there were fewer sessions in Cumb ria because of, I think, transport and road links? ANSWER: Yes, yes. The road link from Newcastle into the Cumbria area, even to Carlisle, remained sort of -- 69 a city in that area -- was one road, the A69, and a big stretch of it was not even divided. It was j ust single track in each direction. And we ended up -- the arrangement was that the team would go out on o ne day and then they'd be put up in a hotel, and then they would run the session the next day and perhaps stay overnight another night, do another session, a nd then come back. So it was complicated. It was tim e consuming. It was expensive. So the Cumbria area was underserved.
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QUESTION: You told us in your addendum statement that there w as a satellite office in Middlesbrough, known as the Teesside office. Did the donor sessions in that ar ea take place at the Teesside office or was it a quest ion of mobile questions going out from the Teesside office? ANSWER: No, it was mobile sessions. The sessions essential ly organised the same as the rest of the area, except that the Teesside office did two things: one, it looked after the donors in that area, parts of Nort h Yorkshire, Durham and surrounding areas around Teesside, Stockton -- anyway; and they also managed , as I mentioned, the voluntary team of donor attenda nts from the British Red Cross and the St John Ambulanc e Brigade, somewhat unusual, but interesting. 170
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QUESTION: Then you told us in your main statement that you thought there was an area just north of the Scottis h border which was supplied by the Regional Transfusi on Centre and you didn't recall any blood donor sessio ns being held there but, in your addendum statement, I think your recollection now is that you didn't supply that hospital but you did hold donor session s in that area; is that right? ANSWER: Yeah, I mean that's -- boy, I'm sorry, that's reall y rusty. I think we did hold a session, perhaps in Gretna. I really can't remember. It's so minor, i t's a very, very minor issue. You know, we also crosse d into the Yorkshire Region's area and supplied a hospital. These are, in the big picture, very minor.
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QUESTION: Then, in terms of the general public sessions, were they based upon donors being called up from the pan el or were they drop-in sessions or was it a mixture o f both? ANSWER: We called people to the general public sessions so they were invited by letter. And so, you know, we had statistics that showed, you know, how many people w e invited, and how many turned up. We're very proud of our statistics until we introduced a new computer system and found out that, actually, there were qui te 171 a lot of walk-in donors that we hadn't invited turn ing up. So it's interesting what you find out when you start getting the information. But, yes, public sessions were by invitation. Industrial sessions were mainly the individual companies organised, you know, who would come at wh at time, and so we didn't actually send them out individual letters, and you'll see that factor come s into play when there was the -- when AIDS leaflets were to be sent and distributed.
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QUESTION: Then, if I can just ask you to look at one document from 1988, NHBT0059596_001. So this is a meeting, 12 January 1988 at which you were present and this is from the point in time at which you were a consulta nt haematologist at the centre but not the director. If we just go to page 5 and pick it up under "Any Other Business", the second paragraph refers t o you presenting the donor panel statistics for 1987. You note there'd been a continued fall in the intak e of blood and the number of new donors attending had fallen still further. Relative decline in the valu e of the publicity budget was also noted. Then there 's a further discussion about rejection of donors. Then if we go to the next paragraph, it says: "Dr Lloyd pointed out that for the recruitment 172 of new donors we needed additional funding and this had been requested in the short-term programme for 1988/89. He also felt that if any savings were to be obtained from reorganisation within BTS then a significant part of these resources should be applied to the donor sessions to make them more attractive. Some discussions followed on ways of improving the appearance of donor sessions. It was generally felt that the use of rather dingy church halls left us with an image that was very similar t o that seen in the 1950s. It was clear however there was no easy answer to this problem as good quality accommodation was extremely limited." Then there's a later document, I won't go to it, but there's an article from 1989 which quotes you talking about difficulties in attracting donors giv en the lack of standards. Do you recall what was -- whether you were able to do anything about the issue here of not being attract donors because of -- well, described here a s "rather dingy church halls" and not being attractiv e accommodation or "good quality accommodation" to ho ld the donor sessions in? ANSWER: I mean, we did make some changes in our donor servi ces department, and tried to focus, get some people in to 73 focus on different types of sessions, so that they had more chance of trying to get better accommodation. It was certainly difficult. You know, we were competi ng with other organisations. If you have an organisat ion that wishes to use a nice community centre and they 're going to use it once a week, then we want to come i n on one of their days but only twice a year or four times a year, it -- you know, it's a difficult issu e. So you can't -- it's hard to get better accommodation. It certainly was. Once you have th e accommodation available to you, then you can perhap s start trying to make the session run more effective ly. But that's obviously another issue.
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QUESTION: Do you know what consideration was given when the general public sessions were being held to creating opportunities for privacy, so that donors could spe ak in confidence perhaps to the medical officer, especially if they're being asked questions about high-risk activities? ANSWER: No, it wasn't good. I think we used to use an area -- we had a screened area in our sessions, which wasn' t sort of wonderful, but you could take the donor out of the main area and into this -- an area with screens around. I think it was sometimes used for someone who wasn't feeling very well, as a recovery. And there 174 was also a screened-off area where they did some wo rk on the bags after collection. So donors could be taken out of the main area. Certainly not perfect but they weren't being -- when you got away from the initial questioning to go into something more detailed, there was an opportunity to go to a sligh tly more private area.
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QUESTION: In terms of the workplace or industrial sessions on which you've already told us the region was very heavily reliant, was any consideration given to concerns that a workplace donor might not be a trul y voluntary donor because they may feel pressured to give blood if their employers had arranged a sessio n? ANSWER: Yes, I mean that's a valid concern. I don't recall that we did anything to try to alter that. The don ors in workplace sessions, I don't know how much in the -- they were put under pressure. It's hard to tell. You know, perhaps some confidential surveys might have been a good idea. But, yeah, there's always a risk in any group, whether it's a family, you know, members of the family or extended family donating, pressures there. Pressures of work, certainly possible. We never tried to pressure the workplace to, sort of, push people into donating. It was very mu ch, you know, you'd bring as many people as you can, bu t 175 if the numbers dwindle we're not going to sort of s ay, "Hey, you must, must, must get more people!" But, yeah, it's a valid concern, I agree.
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QUESTION: Do you know whether, in the workplace sessions, aga in, whether there were opportunities for donors to be a ble to speak confidentially, again in the context of discussions about high-risk activities in particula r, it may be particularly problematic for a donor if their colleagues are within earshot, to be candid i n response to questions asked. ANSWER: You had the same physical set-up with the screened area so that's sort of really as good as it got. How close other donors would have been to that would perhaps vary from session to session. You kn ow, in some of the shipyard sessions, you could have difficulty talking to people, they were so far away . You know, a great big hall ...[frozen screen]... wh ere the accommodation is certainly tighter. So -- but the screened area, you know, was available. Not perfec t, certainly.
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QUESTION: Then I'm just going to ask you to look at couple of the graphs you've exhibited to your statement on th e donor numbers. If we start with WITN6935008, pleas e. Oh no, sorry, my fault, Sully. I've given you the wrong reference. WITN6935006, I meant to start 176 with, sorry. So this gives an overall picture of donor numbers from 1947 to 1994 in the region and we can see, obviously, a significant increase overall, but it looks like it remained relatively stable from reall y the 1970s onwards, some increase when we get on to 1993, with a drop in '87 and, I think, '88 in particular. ANSWER: Yeah.
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QUESTION: Do you have any recollection as to what caused that particular drop? ANSWER: Yes, I think there's another chart I've produced wh ich shows employment rates. If you knew the north east at that time, the number of shipyards closing down, yo u know, steelworks closing down, steel fabricators, i t was a very difficult time. We lost -- yeah, we los t a lot of people. And it's very hard, if you lose y our job, to bring yourself to come back and donate and do something voluntary would be hard.
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QUESTION: Then I won't go to the charts but there are two cha rts which look at registered donors and industrial dono rs and then the employment rates, and for the transcri pt they're WITN6935008 and WITN6935009. Can I then ask you little about the process for donor screening. I'm going to start by asking you to 77 look at a national document, CBLA0002307, please. Oh, no, that's not the document I had in mind at all. ANSWER: Probably not.
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QUESTION: Okay, let's try a different version. DHSC0046337. Okay, so this is the 1985 version of the "National Blood Transfusion Service Guidance for th e Selection, Medical Examination and Care of Blood Donors", and if we go over the page, we can see the re it starts with a section on the "Selection of Donor s". Now, Dr Lloyd, we've got a version from 1977, a version from 1984. This one is 1985. ANSWER: Yes.
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QUESTION: We've got later versions from '87 and 1990. Until you introduced your own selection booklet, was this the guidance that was used, do you think, some form of -- one of the -- ANSWER: Oh yes, yeah.
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QUESTION: -- versions of this? ANSWER: I mean, this document is very familiar to me. I me an, you could pull up several from different years and they don't change a lot, but this was the base for the selection of donors that we used. I mean, we didn' t deviate particularly from this, it's just that we tried to make something that was easier for our sta ff 178 to use so that they could be more effective in selecting donors.
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QUESTION: And if we go to the next page, please, this sets ou t the questions that the donor session clerk should a sk about medical history. And then we've got a number of conditions listed. We can see AIDS would lead to disqualification. Blood transfusion in last six months is referred to the medical officer. Can you recall what the practice was in the Northern Region if there was someone with a blood transfusion in the last six months? ANSWER: Well, they would be deferred, as far as I can recal l. For some reason I thought it was longer than six months, but yes, we deferred blood donation within the last six months. I see there in that document it says, "Blood donation within 4 months", "Action: Wait", which is don't take. In six months , presumably meaning between four and six months, "Re fer to MO". I'm not sure why there was that distinction between four and six months. I'm not sure what the logic behind that was. But this is the sort of document we would have used, and so we would have followed, you know, that instruction, "Refer to MO" . 179
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QUESTION: Yes, if we go then to the bottom of page 6 because you'll see it says, "See note ix", and then -- ANSWER: Okay.
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QUESTION: -- note ix is at the bottom of page 6: "Transfusion of blood or blood products received in the last six months." Then it says: "6 months minimum depending on nature of disease or injury." ANSWER: Yeah.
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QUESTION: In any event, if we then go back to page 4, please, I just want to pick up a couple of other conditions or situations. So the third item down here is "Drug abuse ... Disqualify." Can you recall what procedures were t o try to assess whether somebody fell into that category? Were there specific questions that were asked or was it very much dependent upon that information being volunteered? ANSWER: I don't think people are going to volunteer to answ er and say, "Do you abuse drugs?" Looking back on thi s, you think that perhaps the wording being used was n ot really appropriate. "Am I drug abuser? Oh no, but I did use drugs once. You know, I did inject myself at that party. " 180 Is that person a drug abuser? Do they consider themselves to be a drug abuser? So I think, you kn ow, our wording is not that -- was not very good. I th ink it changed later. But as to weeding out who might be at risk, I don't think we -- we probably didn't do a great job at it.
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QUESTION: Then if we look further down the page, we've got: "Hepatitis ... Refer to MO ... See appendix 1" And we see the same at the top of the next page, it says, "Jaundice ... Refer to MO ... See appendix 1". If we just go to appendix 1, page 12, please. So we can see it's the fifth paragraph down, headed "Hepatitis". ANSWER: Yes.
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QUESTION: "Individuals who give a history of jaundice or hepatitis or in whose blood anti-HBs is present may be accepted as donors providing they have not suffered from jaundice or hepatitis in the previous twelve months, have not been in close contact with hepatitis or received a blood transfusion of blood or blood products in the previous six months ..." As far as you can recall was that the practice at the Northern Region, that someone with a history of jaundice or hepatitis could donate if it was more t han 81 12 months ago? And subject obviously to the HBsAG -- ANSWER: I mean, at that time, you know -- at that time I do n't recall that we would have done anything other than follow this. I certainly don't recall anyone sayin g we should have a different arrangement. We followed -- you know, in this case we followed thes e guidelines as they came out every few years. Yeah. I think that's -- I mean, I don't have documentary evidence to say that we did anything different. So yes, we would have followed this.
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QUESTION: Then if we come to guidance produced by the Norther n Region itself, if we start with NHBT0007497, we can see a letter from you to Dr Gunson, January 1994 saying: "I know you are now getting reasonably close to producing the Selection of Donors booklet. I thoug ht you might like to see the version we have introduce d. The main aim in producing this booklet was to put a ll the possible information together into one alphabet ic section. This means staff are less likely to have to jump from one section of the book to another", and so on. Then if we go on to NHBT0007498, we've got the booklet or a version of it dated December 1993 -- ANSWER: Yes. 182
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QUESTION: -- so probably what you were referring to in your letter to Dr Gunson? ANSWER: Yes.
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QUESTION: If we go to page 5, we can see, under the heading "Introduction", it provides: "... the information required to assist staff of the Northern Region Blood Transfusion Service in th e process of selecting Blood Donors and Donations wit h regard to both the safety of the donor and the safe ty of the donations for transfusion and for further processing into plasma derived products." Do you know whether there have been any -- or can you recall whether there was any earlier versio n of a locally produced booklet or was this the first time that one had been produced? ANSWER: I think this was the first one. It is marked as Version 1. So I think don't think we produced an earlier one of this. It took some time to produce this and, as I say, it was part of our -- what we w ere trying to do was make it easier for the staff to ge t the information and use it. This was probably introduced at about the same -- I think we introduc ed the information on medication, might have been a bi t earlier but, yeah, I don't think we did anything separate prior to this. 183
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QUESTION: Then if we look towards the bottom half of this pag e, "Rationale": "There are two major considerations with regard to donating blood. These are: "(i) That all care should be taken to protect the voluntary donor from harm, and. "(ii) That the blood or plasma collected should be safe for its intended use. "In addition to this it is the policy of the NRBTS not to take donations of blood or plasma from donors unless at the time of collection, it is believed that the donation is suitable for use. It is unethical to accept donations from donors in the knowledge that the donation is unlikely to be used because it does not meet specifications. Unusable donations also represent waste of materials, money and the time and effort of members of staff." Had that always been the policy of the Northern Region or was that a shift which you introduced? ANSWER: That was a shift. Perhaps not as massive as it loo ks there. But we did collect ...[frozen screen]... it was --
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QUESTION: I'm sorry, Dr Lloyd -- ANSWER: -- remember we had -- sorry?
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QUESTION: You froze there for a moment. Sometimes when you 184 freeze I don't think we're losing what you're sayin g but I think we might have done there. ANSWER: Okay.
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QUESTION: So the last we heard was you said, "But we did collect", and then we lost you. ANSWER: Okay, yes. We did collect donations that we couldn 't use. Our statistics, as we gradually built up our information systems in the centre, we realised that we were taking a lot of donations that weren't either being used at all, or were only being partially use d. And we felt that was not good for the Centre and it wasn't good for the ...[frozen screen]... medical staff meeting, there was a question about someone w ho was homosexual and, you know, should we take a donation from them just, you know, so it looks ni ce and then throw it away? Well, no, we shouldn't. So it was a change. We were trying to do what we said in this document and, obviously, we hadn't done it before this time.
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QUESTION: Then if we go to page 7, we've got the heading "Medical Assessment": "In practice it is impossible to perform a complete medical and physical examination of every prospective donor. A significant part of the assessment procedure will usually rely on answers t o 85 simple standard questions relating to general healt h, past medical history and medication. This is combi ned with simple visual assessment of the donor and selected testing of samples collected at the time o f donation." Then the next paragraph refers to donors undergoing medical investigations. Then this: "Where doubt exists, the donor should be deferred and permission obtained to contact the Donor's [GP] or other appropriate Medical attendant ." Then: "Any active and/or chronic disease which may be transmissible, should be a reason for permanent exclusion." In terms of the "Where doubt exists, defer and seek permission to contact the GP or other" -- ANSWER: Lost you. In terms of these?
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QUESTION: The paragraph which begins "Where doubt exists, the donor should be deferred" -- ANSWER: Yes.
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QUESTION: -- was that a shift in policy at this time? ANSWER: I think we were moving more to excluding, if we wer e in doubt, rather than collecting the donation and perhaps following up afterwards. Now, in terms of the safety of the blood we collect, you might argue tha t 186 that doesn't make a big difference, as long as you have a doubt, and that is acted upon, donation is p ut on hold, and then we follow it up. That's probably not a dramatic change because we were all -- you kn ow, we'd always done that. But what we're trying to do is actually not take the donation in the first place.
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QUESTION: We can take that down. Thank you. What systems or processes did you put in place to try and avoid donors whose donation might well e nd up getting rejected from attending in the first pla ce? How did you tackle that issue? ANSWER: I mean, two things. One is with a document like th e selection document you've just seen, and working wi th the staff to -- who went out and did this work, to try to, you know -- when I started, there were very few training sessions for anybody. So, you know, we gradually introduced more training, gradually introduced standard operating procedures, which sta ff were required to read and understand and be shown t o understand. So that we were trying to get the sess ion staff to understand what we were trying to do as an organisation. So we did a lot more training and I think for the first time we started having training sessions back in the Centre for the medical officers. I don 't 187 recall that ever having happened in the past and so now we were bringing medical officers in for -- whether it was a day or an afternoon, I can't remember -- but we had training sessions. So we -- you know, trying to change the, sort of, attitude a nd our approach, and it's very hard to know if we were successful.
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QUESTION: You talk in your statement about trying to ensure t hat donors were informed about donation criteria before attending, to avoid them wasting their time if they turned out to be ineligible. ANSWER: Mm.
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QUESTION: Was that done by sending out standard literature wi th the call-up cards, then? ANSWER: Well, in one of my documents that I attached to my witness statement, you'll see a leaflet that we produced. You'll see it stands out. It's white wi th a lot of red lettering on it and most of the text i s blue with headings in red. I can't remember what number it was but we produced -- that was one of th e things we produced and sent out with all the call-u p. And that -- You know, the thought process, if you've come to a session it's taken you a long time, perhaps, to g et there. You may be with a family member or a friend , 188 and then we go into the peer pressure thing, and you're presented with an AIDS leaflet at the sessio n, that's a little bit late, a little bit harder to ge t out. If you've had that in the privacy -- you know , a letter sent to you personally, you might be able to make an informed decision prior to making -- going out to a session. So try and give them more informatio n. And it wasn't just about, sort of, the safety issue it was also about looking after the donors an d making things easier. There were a lot of simple things where donors are not able to donate, so -- a nd they only found that out after they'd come to the session. So give them that information before the session, it may save them the journey to a church hall, which might be, you know, a few miles away. And so it will save them time and effort and hopefully mean that if circumstances change they'll be more prepared to come back again.
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QUESTION: The letter that you referred to that you exhibited to your statement is WITN6935020. ANSWER: Yes.
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QUESTION: It's not, I think, dated but I think it must be aft er 1989 because, if we just look at the letter on the right-hand side: "Dear Donor, 89 "On behalf of the Blood Transfusion Service in the North East and Cumbria, I would like to take th is opportunity to thank you for your willingness" -- ANSWER: Yes, we put a date.
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QUESTION: -- "to help us by donating blood. "During 1989 there was an increased demand for blood and blood components and I am very pleased to say that many more donations of blood were given, helping us to meet that need. This year it is clea r that even more blood is being used and still more donors will be needed." Then the next paragraph talks about the value placed upon the voluntary nature of the donation. Then if we just go, next paragraph down: "In this leaflet there is information about donating blood which I hope you will find useful. In particular it is designed to help avoid the annoyin g situation where after going to a blood donor sessio n you find that your donation cannot be accepted beca use you may have taken some tablets recently, or perhap s you have travelled to certain foreign countries recently." Then there's an opportunity to telephone a number for further information, and then the next paragraph says: 190 "... I hope that this leaflet will help you avoid a wasted journey or a long wait at the sessio n." I'm going to ask you separately about some specific issues relating to the AIDS leaflets but, in terms of this kind of letter, this personal letter being sent out to donors, was this the first time t hat this was done in 1990, probably, I think, or was th is something that had been done earlier, do you know? ANSWER: Oh dear, I can't remember. I happen to have a copy of this leaflet in one of my old files here. So, you know, it sort of brought it back. But I can't remember -- it's the sort of thing that we would have -- we were trying to do. So I wouldn't be surprised if we hadn't done it a little bit earlier but, you know, 1990, did we do it before 1990 ...[frozen screen]... first.
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QUESTION: I'm sorry -- ANSWER: -- given the timing -- and, oh --
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QUESTION: We missed a bit there. So you said -- ANSWER: Okay.
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QUESTION: -- you asked the rhetorical question: did we do it before 1990? Then we lost it for a few seconds. ANSWER: Okay. Looking at the timing and thinking back abou t our thought processes of changing how we, you know, dealt with donors, this is probably the first one w e 191 put out.
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QUESTION: Then, if I can ask you to look at your statement, WITN6935001, page 10. It'll be the bottom half of the page, please, Sully, when we get to it. So, in that long paragraph at the end, just over halfway down, you say: "In the past many donations were labelled for 'laboratory use' because of limitations in the donation process." What kind of limitations were you referring to there? ANSWER: The donation process doesn't mean, in that context, just putting the needle in the arm. It's the whole process of the session, and selecting the donor and -- so it is the whole process. So -- and then it refe rs to the fact that new documentation was produced to support the clerical staff, providing clear information. So we -- this is part of this process: let's not do what we did in the past and collect blood for wh ich we really had no use.
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QUESTION: We can take that down -- ANSWER: It's not fair to the donors.
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QUESTION: And then what, if any, systems were in place at the Northern Regional service to ensure that a donor wh o 192 had been excluded from giving blood in your region would not give blood in another region? Was there any way of ensuring that? ANSWER: Oh no, no, I don't think so. If we excluded someon e, I don't think there was any -- I don't recall sort of a system of broadcasting that information to other transfusion centres.
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QUESTION: And do you recall any occasions in which your servi ce was notified by another regional service of a donor who'd been excluded? Or deferred? ANSWER: I do not recall that happening. It's a lot of year s ago, but I don't recall it, no.
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QUESTION: I just then want to pick up on a couple of what mig ht be regarded as high-risk groups. So prison donatio ns, first of all. If we look at NHBT0008628_001. This is a document that was put up together for a Scottish Transfusion Directors' meeting in September 1983. It says: "Telephoned survey ..." ANSWER: Yes.
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QUESTION: "... of England and Wales Transfusion Centres regarding use of prisons as a source of donor blood ." ANSWER: Yes.
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QUESTION: I think this may have been an exercise undertaken b y Dr Brookes, but I -- 93 ANSWER: I think it probably was.
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QUESTION: And obviously it sets out the position in relation to a number of regions. But if we go over the page, t he second region is yours, Newcastle. "Long ago stopped holding session is Durham and Northallerton but continued to use an 'Open' prison in West Cumberland which housed 'civil crime' prisoner s (bigamy, fraud, etc). "Latterly they had noticed an increase in incidence of hepatitis B markers and discovered tha t prisoners from Walton Jail (Liverpool) were being s ent there for their pre-release 6 months. "This session has now been dropped, so that Newcastle now holds no prison sessions." Now that's as at autumn 1983. Do you know yourself how long before that this practice had bee n dropped? ANSWER: No, I don't. I mean, I do -- you know, I recall, a nd I think I said it in my initial witness statement, that I thought we didn't hold sessions at prisons, in my time, and I mean by that going back to 1981, 1980/81, when I first worked in the transfusion centre. But then I saw this, and obviously it make s it possible that we held sessions at that facility in Cumberland after 1981, but prior to ...[frozen 194 screen]... Dr Anne Collins telling me that they had stopped -- actually telling me this information: th at they had stopped taking blood from prisons because of the higher rate of hepatitis B markers. So she did tell me that. And she would have ...[frozen screen]... one maybe, you know, I can't be absolute ly sure but it was in that early phase when I was firs t starting working there, and I recall her telling me about this.
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QUESTION: We lost you for a couple of seconds, a couple of occasions, Dr Lloyd. I'm just going to read back broadly what you said and see whether we caught all of it. So you said it may be "possible that we held sessions at that facility in Cumberland after 1981" . Then you referred to Dr Collins telling you that they'd stopped because of the higher rate of hepatitis B markers. ANSWER: Mm-hm.
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QUESTION: Then you say you can't be sure but it was in that early phase when you first started working there an d you recall her telling you about this. So is it right to understand it's in the 1980/81 period that is your best recollection of when she t old you this? 195 ANSWER: That's my best recollection. I sort of feel that i t was something that she told me early on, certainly when I was still a registrar, or locum registrar. So it's the '80/81, possibly '82, but I sort of feel t hat it was probably in the earlier part because I do recall, you know, this thing: we don't do sessions in prisons anymore. And that came from other people a s well.
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QUESTION: You tell us in your statement this, you say: "I recall from informal discussion with staff in the Centre that it was known that prisoners were gi ven privileges for donations such as cigarettes. This went against our policy -- ANSWER: Yes.
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QUESTION: -- of not offering inducements to donate." ANSWER: Mm-hm.
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QUESTION: Were you being told or led to understand that that was something that was being given out by the Transfusi on Service or by the prison? ANSWER: I mean, first of all, that was not -- those session s weren't occurring at the time. This was a historic al information. But those -- the cigarettes were give n out, as far as I -- you know, they were given out b y the prison staff. We didn't -- unless I'm extremel y mistaken, we didn't supply cigarettes. But I think 196 the prisoners would get a benefit of some cigarette s for donating. And that came from the prison.
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QUESTION: And then do you recall whether the Northern Region collected blood from military institutions, barrack s or Air Force bases or the like? ANSWER: Yes, we did. I'm pretty sure that we went to Catterick barracks, near Northallerton, actually in north Yorkshire. And we also went to a small -- I think it was -- I can't remember if was run by th e Royal Navy or the Royal Air Force, a munitions depo t in the Carlisle area. So we certainly did those tw o. The munitions depot would have been a slightly different beast to the Catterick garrison, but yes, I believe we did.
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QUESTION: And were there any US bases where donation sessions were held? ANSWER: No, as far as I -- well, I know we didn't do any sessions at US bases, and I don't know that there w ere any US bases in our region. There might have been an Air Force base and some facilities around the North York Moors, but no, we didn't do any sessions at US bases.
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QUESTION: Can you recall whether any active consideration was given to the position of those donating at military sessions, that, again, they may not be truly volunt ary 97 or it may be even more difficult for them to admit to high-risk activities than it might be in other settings? ANSWER: Yeah, yeah. Yes. No, I don't think we did give consideration to it. I don't recall us discussing that. So yes, they -- you know, "You, you and you will donate today". It's certainly possible.
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QUESTION: And then you referred earlier to the position of people coming along with family members to donate a nd the difficulties that might arise there. ANSWER: Mm-hm.
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QUESTION: I just want to pick that up by reference to a docum ent you exhibited to your statement, WITN6935018. Some notes, I think authored by you, headed "Transfusion - Do We Have Any Choice?" I'm going t o come back to what you say elsewhere in this documen t tomorrow, but if we just turn to page 4, halfway do wn the page it says: "This leaves two more areas: "Predeposit and something that I have not mentioned before - Directed donations." Then you say: "Directed donations are those made by family or friends for a patient. This sounds like a good ide a. My 'brother', 'sister', 'aunt', 'uncle', 'best 198 friend', 'neighbour' cannot possibly be at risk of HIV/Hepatitis/Venereal Disease etc, hence much safe r than the blood donor." Then if we look in the next -- sorry, at the bottom of the page. You say: "... Voluntary donors are safer." This is the last three lines: "Family members who are not volunteer donors are therefore ordinary members of the population with a higher risk of HIV infection and other infections ." We haven't, I think, with other witnesses, discussed this particular category of potential donors, the directed donation. What was your think ing here? ANSWER: I mean, these were just notes I made for myself rea dy to give a talk at a hospital -- at a hospital I-- anyway. Um, my thought process, as you see there, it can't -- you know, "Someone in my family can't possibly be at risk". You sort of have this innate feeling that your family and friends must be, you know, very good, very clean living or whatever. An d so if you -- and this was very much about directed donations not going to an ordinary voluntary sessio n.
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QUESTION: Yes. ANSWER: So it would be nice to -- you know: let's get our 199 family to donate for another family member or for a friend in hospital, so we direct the donations because they must be safer. And I was saying: well , no, there's not really any evidence that they're safer. And in fact they may be less safe because t hey are under social pressure, as you've alluded to in other cases, they're under social pressure to donat e. So I -- perhaps around that time directed donations was something being talked about, so I thought it would be a good thing to bring up in a talk.
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QUESTION: I want to then pick up the issue of AIDS. How and when, as far as you can recall, did you first becom e aware of AIDS and it's potential transformation through blood or blood products? ANSWER: It's hard to remember when. I mean, you know, duri ng training, you know, you read a lot so you know that there's a problem. And, you know, I recall reading the -- the earliest journal articles talking about this new disease, that something was happening. So , you know, we're going back to the very early days o f this, because I recall these articles and they're saying, "Well, we don't know what's causing it". There were even people saying with haemophiliacs it might be due to some odd change in the constitution of Factor VIII by fractionation which is impairing the ir 200 immune system. So I've been aware of transmission certainly since, you know, some of those early articles start ed to confirm out in the States.
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QUESTION: Again, putting it back in the context of your own career, you were in that period, 1982 through to sa y 1984, that was your I think senior registrar traini ng when you were doing the rotation between the differ ent hospitals? ANSWER: Mm-hm.
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QUESTION: So do you recall any sense in the haematology community at that time any particular sense of urge ncy or concern about the potential threat that AIDS pos ed? ANSWER: Goodness. Um ... I don't recall that terrific sens e of urgency. I mean, I recall seeing some of the fi rst haemophiliacs who were exhibiting signs and symptom s associated with AIDS when I was at the RVI. So, yo u know, people -- we knew there was -- this was going on, this was happening, but did we know it was happening amongst non-haemophiliacs? People receiv ing regular transfusions? No, I don't think we did. It would have been unusual, because the number of people we -- donors we picked up once we started testing for HIV, the numbers were very, very small. So the likelihood of this being an issue that was 01 being brought to people's attention on a regular basis, with people getting it from transfusion in t he Northern Region was low. We knew about it from oth er regions, and certainly I don't think there was a terrific -- I don't feel a terrific sense of urge ncy amongst the general transfusion population -- you know, haematologists. But you should ask them.
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QUESTION: And just in terms of seeing haemophiliac patients w ith early signs at the Royal Victoria Infirmary, again, just trying to put that in a chronological context, you told us earlier that you thought your RVI placement was the third of the three. ANSWER: Mm-hm.
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QUESTION: So would that have been around 1986, then, that you were there? ANSWER: Um ...[frozen screen]... '86, I'm trying to -- I honestly, you know, my -- one of the things I fou nd about this whole business is that I have difficulty putting things into sort of chronological order, an d I do find at times that I am not quite sure. So I wouldn't like to be sure but I, you know, as you said, I believe my RVI placement was the third of f our in that block so it would have been in the latter part. So you're probably about right.
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QUESTION: Then perhaps just one more document before we finis h 202 for today, WITN6935027. These are handwritten note s. Are they your handwritten notes? ANSWER: They are indeed.
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QUESTION: They're remarkably legible, in that case: "The Acquired Immunodeficiency Syndrome and the Human T-Lymphotrophic Leukaemia Viruses. "Notes made at a symposium held at the London School of Hygiene and Tropical Medicine on 3rd April 1985. With some additional material from a Brief review published in Blood, February 1985, a nd the Interim guidelines from the Advisory Committee on Dangerous Pathogens." So it looks, Dr Lloyd, as though you attended this symposium in April 1985. Can you recall what prompted you to attend? ANSWER: This was a major issue -- I mean, AIDS -- and so, y es, I wanted to go to this. It wasn't just a, sort of, a routine one of the conferences coming up. I certainly wanted to go to this. It was -- and as you can see -- I mean, what you see here, I only reproduced a couple of pages, the first and last, a nd perhaps the one in the middle. It was a longer document and I took a lot of notes.
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QUESTION: If we go to the second page, there's a heading, nea rly halfway down, "Mode of Transmission", and then the 203 second paragraph under that records: "The transmission by blood or blood products is now well documented, and this includes 'needle stic k' injuries in staff handling infected materials, intravenous drug abusers sharing needles and patien ts receiving blood or certain blood products. It appe ars that Human Albumin Solutions (PPF) do not transmit the virus, nor do intramuscular preparations of immunoglobulin. Factor VIII concentrate is known t o transmit HTLVIII, and one case is documented of a patient who had received only UK produced [Factor VIII] concentrate developing AIDS." Then if we just go to the next page, it's the last long paragraph -- ANSWER: You can see there's a lot of pages -- a lot of page s missing. I think that has "Page 12" at the top.
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QUESTION: It does. ANSWER: I didn't attempt to reproduce the whole thing.
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QUESTION: It says: "Prospects for limiting the spread of the disease including encouraging homosexual men to lim it the number of partners they have, to use condoms, a nd presumably once known to be HTLVIII antibody positi ve, to refrain from sexual contact." Then you go on to talk about the implications 204 for transfusion: "For blood transfusion, all donations should be screened for HTLVIII antibody -- as tests are now available, although not yet as commercial kits. Potential donors from risk groups must be excluded as far as possible. Effective literature and advertis ing campaigns should be used. All plasma for processin g should be tested and treatment of finished products should be carried out to render the product non-infective. Heat treatment of [Factor VIII] concentrate may render the product non-infective, b ut at the cost of a 50% reduction in potency and a resultant increase in [cost]." So do you recall anything more in relation to that symposium, any further discussions about the implications for blood transfusion and the measures that should be implemented in the Transfusion Servi ce? ANSWER: No, I don't. I mean, I have the document, and if y ou want to see my whole document, I'm quite happy to s can it and let you read it. But now, off the top of my head, I can't remember all the other things that were -- that I wrote. But, obviously, this sort of colours your -- informs your view of the issues, certainly. I mean, we can see that we've got a problem. 05
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QUESTION: Now yesterday we had looked at your notes from that April 1985 symposium on AIDS, where you outlin ed some of the measures that might need to be consider ed by the Transfusion Service. Before we look at thos e measures, just one other matter relating to a respo nse to AIDS that I wanted to ask you about. In 1983/84/85 you obviously weren't based at the Centre. Do you know, either from discussions w ith Dr Collins or discussions with Dr Peter Jones or through any other route, whether Dr Collins was eve r asked to increase the production of cryoprecipitate at that time? ANSWER: Right. Production of cryoprecipitate was very much on a -- it's a daily decision. Although it's a frozen 64 product, you can store it, so you look at how much you have in your store, and you decide whether or not t o produce more. You don't necessarily produce it eve ry day. You would hopefully -- you would tend to do a run, particularly in the old centre, where the production was in a different building. But there was no -- there's no problem in producing more cryoprecipitate, it's not a difficult thing to do. Once you're set up to produce it, you know, you can turn the tap on. You can say: today, instead of making just plain FFP for clinical use, fresh froze n plasma for clinical use, we'll make cryoprecipitate . And so you can do a run of another hundred that day if you so wish. So as far as I'm aware, we never -- we just produced, the Centre -- in Anne Collins' day, the Centre just produced enough cryoprecipitate to be s ure that there was product on the shelf for when it was requested. So if we were asked for more, then yes, we would produce more. It wasn't a big issue.
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QUESTION: But as far as you know, and it may be you simply do n't know, was a request -- any particular request for m ore as a response to the threat of AIDS in that early period, do you know whether that was ever made to 5 Dr Collins? ANSWER: I don't recall her ever saying that she had receive d a specific request. We've seen some of my data tha t shows that the amount of cryoprecipitate going to the RBI and therefore the Haemophilia Centre was actually going down a little bit. But they could h ave requested more. We obviously had the product.
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QUESTION: Thank you. Now I want to move, then, to the donor leaflets introduced in 1983. Again, I'm very conscious that you were not in post at the Centre at that point in time, but I'm going to ask you to look at a couple of documents in any event. If we start with NHBT0020668. So, Dr Lloyd, this was a letter sent by Dr Wagstaff from Sheffield, 6 July 1983, to his Regional Transfusion Director colleagues, enclosing , over the page, what was intended to be the final version of the AIDS leaflet for national use. ANSWER: Yes.
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QUESTION: Again, I'm not going to go through the detail of th e leaflet. Now, that was early July 1983. The Inquiry knows from other evidence that the Department of Health became involved and the final leaflet was on ly 66 issued at the beginning of September. And we'll just look briefly at that for the benefit, really, of those watching. BPLL0007247. There we have the national leaflet from September 1983. Do you know, either from your later involvement or, again, from conversations with Dr Collins, whet her in Newcastle any earlier leaflet of Newcastle's own devising was introduced, or whether Newcastle waite d for the national leaflet? ANSWER: Sorry, I've lost you: "or whether Newcastle was ... "?
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QUESTION: Whether Newcastle introduced, as some centres did, their own earlier leaflet or whether Newcastle wait ed for this national leaflet to become available in September? ANSWER: I'm certainly not aware that we issued anything earlier. I can't say we didn't, but I personally a m not aware of it.
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QUESTION: And then I'm again going to ask you to look at a document you wouldn't have seen at the time but i t gives us some information about the method of distribution of the leaflet deployed at Newcastle. ANSWER: Mm-hm.
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QUESTION: CBLA 0001820, please. This was a table compiled for the Advisory 67 Committee on the National Blood Transfusion Service , "AIDS leaflet - First six months experience". ANSWER: Yes.
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QUESTION: And we just need to look at the entry for Newcastle at the top of the page: "Distribution Method "With call-up cards "Displayed on industrial sessions. Issued to Citizens Advice Bureaux STD Clinics "No. used 110,000, "Stock 3,000" Then we have: "Donor Response, Effect on Attendance "Nil. 2 or 3 resigned because of homosexual relationships" Then: "Other Comments "One donor [I think that should be] [thought] he could contract AIDS from donation. 'Who is at Risk ?' (final ..." That might be "paragraph" or "part". ANSWER: Paragraph.
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QUESTION: "... may be read as 'if you get jaundice you may [g et] AIDS'. Majority don't know what Hepatitis B is." So we can see there, I think -- please let me 68 know if this is your understanding, Dr Lloyd, three methods of distribution there described. In terms of the general public it would appear that the leaflet was being sent out with the call-u p cards, so donors could take a decision in advance about not attending. ANSWER: Mm-hm. Yes.
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QUESTION: And then in relation to the industrial sessions, wh ere presumably the Centre wouldn't know who individuall y would be attending, it was on display. And then Newcastle then took a further step, which is to provide the leaflet to local Citizens Advice Bureaux and STD clinics. Was that still -- ANSWER: Mm-hm.
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QUESTION: -- the system of distribution with later versions o f the leaflet when you came back to the Centre full time? ANSWER: Yes, we sent out AIDS leaflets when they were chang ed, so they went out with the call-up cards. They were more like little cards than letters in the earlier days. But yes, we sent out a new -- new versions a s they became available, so we would do a new distribution, but we still had the issue that at industrial sessions, you -- we didn't individually call up, the call-up was done within the factory or 9 office complex. So then it was a matter of just displaying it at the clinic, which is not as good a situation as providing it in advance, I have to s ay. So yes, we continued to do this.
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QUESTION: Now, we've -- the Inquiry has heard evidence from the North London Regional Transfusion Centre about an additional measure which they introduced, which was the completion of a confidential exclusion questionnaire which enabled the donor to, as it wer e, save face, potentially, by ticking a box which mean t that their donation might be used, for example, for research, rather than for transfusion. Do you know whether a system like that was ever in operation in the Northern Region? ANSWER: Now, the confidential exclusion certainly rings a b ell with me and I'm not sure now whether I'm just remembering what North London did or whether it was what we did. It is familiar but, again, I couldn't tell you definitively that that's what we had on th e session, I'm sorry.
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QUESTION: If we then move forward to the point in time or a point in time at which you're at the Centre, if w e go to NHBT0118280, please. So this is a memo from you, Dr Lloyd, dated 22 January 1987 to the session al medical officers and the Regional Transfusion Centr e 70 medical officers? ANSWER: Mm.
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QUESTION: "It may be necessary to explain the risk group in m ore 71 detail, but every care must be taken not to offend donors. If the donor is suitable to donate, he or she should be shown back to the Clerk. "Donors who are not suitable to donate should be offered further advice through an MO at the RTC." Then if we just read paragraph (c): "Donors who are in any AIDS risk group must not be bled. Where there is any doubt about the risk t hey should not be bled, but in either case, the potenti al donor should be sympathetically dealt with and arrangements made for an MO from the Centre to cont act them, especially where doubt exists. Some donors m ay not wish any further contact, and this should be respected. A note giving details MUST be sent to an MO at the Centre in a sealed envelope." Now, obviously this memo has been prompted by the specific issue of questions about visits to Afr ica but if we can just go back and look at paragraph (b ), please, Sully, thank you. You're here emphasising that the medical officer must ensure that the donor has read and understood the AIDS leaflet or the AIDS poster; was that something -- a new requirement that you were introducing at this is point in time or were you emphasising that which th e MO should have been doing, in any event? 72 ANSWER: Goodness. Um ... trying to recall. Reading, you know, what I wrote, it doesn't look to me like I'm introducing something new. I'm just reinforcing an existing situation because of the -- particularl y emphasising the change in risk areas, and I am not sure if they'd all been included in the new AIDS leaflet at that particular moment. I think there w as some delay between recognising larger risk areas an d actually getting that information into leaflets. So, as far as I can see from the way I've written this, I'm just emphasising, you know, what we're already doing.
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QUESTION: We can take that down, thank you, Sully. Can I then move and deal very briefly with the question of the introduction of screening or testin g for HTLV-III or HIV, which was in October -- ANSWER: I'm sorry, I lost you then.
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QUESTION: Can you hear me again now? ANSWER: I lost you again -- could you say -- yes, if you st art that question again.
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QUESTION: Of course. I'm going to ask you very briefly about the introduction of HIV screening at the Centre. M y understanding from the documents and from your statement is that you had no involvement, either in the decision making regarding HTLV-III screening or in 3 its introduction at the Centre; is that right? ANSWER: Yes, that's correct.
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QUESTION: Before I leave the issue of AIDS, Dr Lloyd, and com e on to ask you about hepatitis C screening, I just wanted to ask you about investigation of cases of transfusion-transmitted or possible transfusion-transmitted HIV. I'll do that by reference to a document you've seen and talked abou t in your statement. It's at DHSC0020840_041. You can see, Dr Lloyd, this is a letter from you to Dr Rejman at the Department of Health -- 74 ANSWER: Yes.
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QUESTION: -- October 1992, and it concerned the Department of Health's scheme of payments for those infected with HIV through blood or tissue transfer. You refer to a file relating to the transfusion of a particular individual and, obviously, we're not going to menti on that individual by name. ANSWER: Yes.
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QUESTION: If I just read the first paragraph: "No new information has come to light since the original investigation. I enclose for your information a copy of the report I wrote in 1986 wh ich identifies the donations originally transfused to [her] and the related investigations. One of the t wo units transfused to [her] came from a donor who subsequently donated and was found to be HIV Negati ve. The other donation came from a donor who left our a rea and to the best of our knowledge transferred into t he West Midlands. At the time the Transfusion Centre based at Birmingham had no record of this donor donating and I have again checked with the Donor Service Department at the Birmingham Transfusion Centre and they still have no record of this individual donating. Therefore this leaves the possibility that this donation came from a donor wh o 75 was HIV Positive. On the other hand there is no evidence to suggest that the individual is infectious." Then you refer to information relating to the individual's husband, who had been a donor, and the donation had been tested and was HIV negative. If we go over the page, we can see this was your report from, I think, 1986 where you set out the donation history of the individual and then, as I understand it, the investigations that were then made in relation to those two donors. If we look a t the bottom of the page, we can see in relation to t he second donor, who had donated at a time when no HIV testing was available, you record that: "The donor has left the factory at which the donations were made and has not replied to call-up requests made in 1984 and 1985. One further reques t to attend a donor session is being made ..." Then you go on to set out over the following pages -- I don't think we need to go through them - - follow up of various other donations. ANSWER: Yes.
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QUESTION: Do you recall whether this was the only such investigation which you carried out or were there others? 76 ANSWER: I don't recall any others. You know, the Northern Region didn't -- you know, had a very low incidence of HIV positivity amongst blood donors. I think we're talking perhaps about one in a year. So, on that basis, the chances of a donation which was infectio us for HIV but was negative by test is presumably less than one per year. So it's not a common thing in t he region and, therefore, I can understand that we, yo u know, you're not going to have had many investigati ons because there were very few infectious units at tha t time. So it doesn't surprise me that that's the only one I recall.
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QUESTION: Would we be right to understand this case may illustrate the limitations of the investigations wh ich you were able to undertake because, in relation to the second donor, whose donation may have been the infectious donation, you had no samples post the availability of testing and you were unable to trac k that donor once they'd left the area? ANSWER: Yes, we wouldn't have kept -- we didn't keep sample s for later testing. And I think the donations, if I recall from what I just saw, were from 1982.
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QUESTION: Yes. ANSWER: So, no, we certainly didn't keep samples. We weren 't 7 testing for HIV in 1982. And as you've said, we had -- there were definite limitations on how we further explored the possibility of that individual being HIV positive. Looking back on it, I'm not really sure that they were. It would have been a very -- pretty unusual for 1982 in the region. Not unknown, certainly not, but we didn't -- as you saw, we only followed up to the one transfusion centre in the We st Midlands that we thought the person might have transferred to. We could, and perhaps should, have circulated all the transfusion centres, both in the UK -- in England and Wales and in Scotland. I don' t think there was -- there certainly wasn't a system for doing it, but when you look back you say: well, yes , maybe we -- (a) we should have done more, and (b), you know, maybe there should have been a more formal system that would have made it easier to do this.
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QUESTION: Then if I just ask you to look at a reply from Dr Rejman to you. DHSC0020840_031. So this is a response to you, 4 November 1992, and Dr Rejman sets out in the second paragraph: "It would appear that the donor who failed to re-attend may be the cause of the HIV infection." 78 Then he goes on to set out a protocol agreed with CDSC, and in the last paragraph he explains: "We therefore agreed the following procedure, in an effort to minimise the risk of any breach of confidentiality concerning the donor." And then we can see -- it essentially involves contact being made with CDSC and then CDSC would notify the Department but wouldn't notify the Regio nal Transfusion Centre. We see that over the top of th e page. ANSWER: Yes, yes.
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QUESTION: Do you know whether anything further was done in th at regard? ANSWER: As far as I know, this donor did not come up on the panel, on the CDSC. I think Dr Rejman would have l et us -- would have let me know, so I had no further follow-up from this. I'm not quite sure how the Department planned to deal with the information, should it, you know, come to their attention. If C DSC found that this person had been reported to them or they had information that this person was HIV positive, they were obviously prepared to send this information in confidence to the Department, who presumably would have some method of dealing with i t. And given that there was, you know, a definite 79 drive to understand -- to find people -- find out h ow people had been infected through transfusion, that information would have had to have come back in som e way, and I never had any -- I don't recall any furt her follow-up on this.
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QUESTION: So WITN6935001, please, Sully. Dr Lloyd's witness statement's. And if we go to page 83. So picking it up at the bottom of the page, there's a heading "Surrogate testing for NANB", and you say this in your final paragraph on that page: 80 "I did consider that surrogate testing might have reduced risk, but the use of surrogate testing is difficult in that there was no clear link between t est results and infectivity. I was not opposed to additional testing but it was not being put forward for use in the UK and I acquiesced in this decision given the weight of expertise in the Transfusion Service on the topic." And then the top of the next page, you say: "To decide not to introduce surrogate testing given the information on the reduction in non-A, no n-B hepatitis in recipients was from my limited perspective a decision not to apply a 'maximum safe ty' ethos. I think that a substantive trial in the UK would have provided a better basis on which to make a decision. Data from other countries did not necessarily apply in the UK and from what I have se en, US data was also not current in terms of donor screening and also due to the different blood collection arrangements in the US. "This was not a simple decision to make." We have therefore that -- we have your evidence yesterday, Dr Lloyd, that you think probably ALT testing should have been introduced. The other for m of surrogate -- the surrogate marker potentially in 1 relation to non-A, non-B hepatitis would be the anti-HBc testing. I'll come back to the later question of anti-HBc testing in relation to hepatitis B in the 1990s. ANSWER: Yeah.
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QUESTION: But in relation to anti-HBc testing either on its o wn or combined with ALT testing as a surrogate marker for non-A, non-B hepatitis, do you have any views on whether that could or should have been introduced a t some point in the 80s? ANSWER: That, yeah, that's a difficult -- we know from stud ies that there was an overlap between those two tests, that they weren't defining the same range -- the sa me infectious nature of the donations. I didn't put t hat very well. So you've got two tests, neither of which specifically identifies what became hepatitis C, bu t both do pick up some of it and they pick up differe nt sort of spectrums of it. From what I read, ALT was probably more effective in doing that. Oh dear, we've just lost -- I'm sorry, something has happened at this end.
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QUESTION: We can still see and hear you, Dr Lloyd. Can you s ee and hear -- ANSWER: You can? 82
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QUESTION: Yes. ANSWER: But I've lost my screen completely. Ah, we're back , I'm sorry. I think an auto switch-off occurred.