Infected Blood Inquiry

Statutory duty of candour:

The statutory duties of candour in England, Scotland, Wales (and Northern Ireland, when introduced) should be extended to cover those individuals in leadership positions in the National Health Service, in particular in executive positions and board members.

Statutory duty of candour:

Individuals in leadership positions should be required by the terms of their appointment and by secondary legislation to record, consider and respond to any concern about the healthcare being provided, or the way it is being provided, where there reasonably appears to be a risk that a patient might suffer harm, or has done so. Any person in authority to whom such a report is made should be personally accountable for a failure to consider it adequately.

Cultural Change:

That a culture of defensiveness, lack of openness, failure to be forthcoming, and being dismissive of concerns about patient safety be addressed both by taking the steps set out in (a) above, and also by making leaders accountable for how the culture operates in their part of the system, and for the way in which it involves patients.

The Government should reconsider whether, in the light of the facts revealed by this Inquiry, it is sufficient to continue to rely on the current non-statutory duties in the Civil Service and Ministerial Codes, coupled with those legal duties which occur on the occasions when civil servants and ministers interact with courts, inquests and inquiries, as securing candour.

If, on review, the Government considers that it is sufficient to rely on the current non-statutory duties in the Civil Service Code, it should nonetheless introduce a statutory duty of accountability on senior civil servants for the candour and completeness of advice given to Permanent Secretaries and Ministers, and the candour and completeness of their response to concerns raised by members of the public and staff.

All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care:

Those who have had Hepatitis C which is attributable to infected blood or blood products should be seen by a consultant hepatologist, rather than a more junior member of staff, wherever practicable

In England, Hospital Transfusion Committees and transfusion practitioners take steps to ensure that consideration of tranexamic acid be on every hospital surgical checklist; that hospital medical directors be required to report to their boards and the chief executive of their Trust as to the extent of its use; and that the board report annually to NHS England as to the percentage of eligible operations which have involved its use. If the percentage is below 80% or has dropped since the previous year, this report should be accompanied with an explanation for the failure to use more tranexamic acid and thereby reduce the risk to patient safety that comes with using a transfusion of blood or red blood cells.

Training in Transfusion Medicine:

That those bodies concerned with undergraduate and postgraduate training across the UK of those people who are, or intend to be, working in the NHS ensure that they are adequately trained in transfusion, that the standards by which sufficiency of training is measured are defined, and accountability for training in transfusion be defined.

Implementing SHOT reports:

That all NHS organisations across the UK have a mechanism in place for implementing recommendations of Serious Hazard of Transfusion (SHOT) reports, which should be professionally mandated, and for monitoring such implementation.

If it appears to PACAC that there is sufficient concern to justify a public inquiry, either because what happened and why has caused concern (as the committee sees it) or there are likely to be lessons learned which may prevent similar concerns arising in future, the committee may recommend to an appropriate minister that there be an inquiry.

The Government reconsider whether to maintain its rejection in February 2025 of the recommendations of Sir Robert Francis KC and advice from the Infected Blood Inquiry Response Expert Group of August 2024, which was expressly accepted at the time by the Government, to introduce (as one of six health impact groups which would justify a severe health condition award) the following for people infected with Hepatitis B and Hepatitis C: "Other Hepatitis C associated extra hepatic disorders resulting in long-term severe disability. This includes those currently assessed as the following category on IBSS: Hepatitis Special Category Mechanism (EIBSS); 'Severely Affected' Hepatitis C (SIBSS); Hepatitis C Stage 1 Plus (WIBSS); Hepatitis C Stage 1 Enhanced Payments (NIIBSS)"

The approach of the Infected Blood Psychology Service is adopted so that both a diagnosis made by a psychiatric professional and a formulation-based opinion of all qualified psychological and counselling professionals are accepted as sufficient evidence of severe psychological harm and that such evidence should qualify a person for a supplementary Severe Health Condition award without the additional need to demonstrate a period of consultant-led secondary mental health treatment or assessment/treatment as an inpatient.

The Cabinet Office consult on whether the evidential requirements for exceptional reduced earnings are likely to prove a barrier to people who have sufficient evidence that their eligibility for such an award could with confidence be established on a balance of probabilities, and if so to consider what if any provision might be introduced to enable them to access an award.

The Minister give consideration to there being a supplementary route for people affected. This could include opening the supplemental award for severe psychological harm to people affected. He should involve parents, children, siblings, partners and carers, and their legal representatives if wished, in this consideration.