Volume 7: Medicines and Cosmetics
1. Introduction and overview
Overview and general findings

1.35 At the end of each of the Chapters 3-9 we have discussed the adequacy of the response to the events covered in that chapter, and identified where we saw shortcomings. As in the rest of this Report, we do not intend blame to be attributed to specific individuals save where we have explicitly stated that they should have acted differently.

1.36 A number of general features of what occurred struck us as meriting further consideration and as giving rise to lessons for the future, which we discuss in vol. 1: Findings and Conclusions. We have recorded these at the end of Chapters 5-9, having reviewed respectively medicines, cosmetics and the audit of uses of bovine material.

1.37 Much of what was done reflects credit on the foresight and hard work of those faced with this baffling new disease and with difficult decisions about a proportionate response to the risks it presented to human health. Where things were less well done, common threads were poor communication between Departments, blurred perceptions of risk created by reassuring briefing, confusion between risk assessment and policy decisions, problems over where the lead lay when issues spanned departmental interests, and the management problems of seeking to operate at speed with limited resources within different legislative frameworks and enforcement systems. They were not unique to this sector of the general field of action in the face of this new and deadly disease. In Volume 1 we review that overall scene and the lessons to be learnt from where matters were handled well and where they were not.