Reports & recommendations
103 recommendations from 4 reports, each with the government response on the record. Filter by government response, report or delivery status.
Reports (4)
| Title | Volume | Publication Date | Recommendations | Links |
|---|---|---|---|---|
| Additional Report on Compensation | Additional | 09 Jul 2025 | 26 | |
|
Infected Blood Inquiry Final Report
Volumes:
HC 569-I: Overview and Recommendations · PDF
HC 569-II: People's Experiences · PDF
HC 569-III: What happened and why? (Basic Concepts; Knowledge; Blood Services; Blood Products and Addressing Risk) · PDF
HC 569-IV: What happened and why? (Role of Government: Response to Risk; Haemophilia Centres: Policies and Practice) · PDF
HC 569-V: What happened and why? (Blood Transfusion: Clinical Practice; Screening; Lookbacks; Public Health) · PDF
HC 569-VI: Response of Government and Public Bodies · PDF
HC 569-VII: Response of Government (continued) · PDF
|
Final | 20 May 2024 | 58 | |
| First Interim Report | Interim 1 | 29 Jul 2022 | 1 | |
| Second Interim Report | Interim 2 | 05 Apr 2023 | 18 |
Recommendations (58)
Compensation Scheme
My principal recommendation remains that a compensation scheme should be set up now
The Inquiry recommended the immediate establishment of a compensation scheme. In July 2026, Mabon ap Gwynfor, Cabinet Minister for Health and Care in the Welsh Government, stated that progress had been made establishing the scheme and beginning payments, but noted issues raised by beneficiaries regarding the pace of claims processing and payments (Mabon ap Gwynfor, Jul 2026). Nick Thomas-Symonds, Minister for the Cabinet Office and Paymaster General, reported in April 2026 that over 3,200 compensation offers had been made, with over £2 billion paid in compensation and £1.4 billion in interim payments (Nick Thomas-Symonds, Apr 2026). The National Audit Office found in April 2026 that scheme funding had reached £12.8 billion, following regulations in August 2024 that established the Infected Blood Compensation Authority (IBCA) to administer payments (Gareth Davies, Apr 2026; Gareth Davies, Apr 2026).
UK and Devolved Memorials
A permanent memorial be established in the UK and consideration be given to memorials in each of Northern Ireland, Wales and Scotland. The nature of the memorial(s), their design and location should be determined by a memorial committee consisting of people infected and affected and representatives of the governments. It should be funded by the UK government.
The Inquiry recommended establishing permanent United Kingdom (UK) and devolved memorials. In August 2026, the Infected Blood Memorial Committee stated that memorials will be established in Scotland, Wales, Northern Ireland and England, agreeing that the overarching UK memorial should be in England with a working hypothesis of London (Infected Blood Memorial Committee, Aug 2026). The Committee noted that a decision is still needed on where in England the UK memorial should be (Infected Blood Memorial Committee, Aug 2026). In July 2025, Nick Thomas-Symonds, Paymaster General and Minister for the Cabinet Office, announced the appointment of Clive Smith as chair of the committee (Nick Thomas-Symonds, Jul 2025). In May 2025, the UK Government stated that it was following the recommendation to form a steering committee and that memorials would be provided primarily at public expense (Cabinet Office response, May 2025).
Treloar's School Memorial
A memorial be established at public expense, dedicated specifically to the children infected at Treloar’s school. The memorial should be such as is agreed with those who were pupils at Treloar’s.
The Inquiry recommended establishing a memorial for children infected at Treloar's School. In December 2025, the Infected Blood Memorial Committee reported that local council planning permission had been granted for a finalised bronze sculpture design at the school, with working with an artist and foundry to build it remaining outstanding, though agreement with former pupils was not mentioned (Infected Blood Memorial Committee, Dec 2025). Earlier, in July 2025, Nick Thomas-Symonds, Paymaster General and Minister for the Cabinet Office, announced to Parliament that Clive Smith had been appointed chair of the memorial committee (Nick Thomas-Symonds, Jul 2025). In May 2025, the UK Government accepted the recommendation, confirming that a dedicated sub-committee would consider the memorial and that it would be funded primarily at public expense (Cabinet Office response, May 2025).
Community Support Events
There should be at least three events, approximately six months apart, drawing together those infected and affected, the nature and timing of which should be determined by a working party as described above, facilitated by some central funding.
The Inquiry recommended at least three support events for those infected and affected. In July 2026, the Infected Blood Memorial Committee reported spending £169,525.88 on commemorative events, noting that the time and date of a third event remained to be determined (Infected Blood Memorial Committee, Jul 2026). In July 2025, Nick Thomas-Symonds, Paymaster General and Minister for the Cabinet Office, announced that Clive Smith had been appointed chair of the committee (Nick Thomas-Symonds, Jul 2025). In May 2025, the UK Government stated that a sub-committee would be established to organise biannual networking and support events (Cabinet Office response, May 2025).
Medical Education - Curriculum
The General Medical Council, and NHS Education for Scotland, Health Education and Improvement Wales, Northern Ireland Medical and Dental Training Agency and NHS England, should take steps to ensure that those “lessons to be learned” which relate to clinical practice should be incorporated in every doctor’s training.
An action log owned by Emma Watson of NHS Education for Scotland, as minuted by the Scottish Government in March 2026, recorded that funding had been agreed with the body to take forward recommendation 3 (The action log, Mar 2026). In November 2025, she reported that a group led by NHS England to address the recommendations had been disbanded due to funding constraints (Professor Emma Watson, Nov 2025). Earlier, the UK Government stated in May 2025 that the General Medical Council was surveying educational institutions and working with four-nation leaders to identify training gaps (Cabinet Office response, May 2025).
Medical Education - Training Materials
They should look favourably upon putting together a package of training materials, with excerpts from oral and written testimony, to underpin what can happen in healthcare, and must be avoided in future.
An action log for Professor Emma Watson of NHS Education for Scotland, minuted by the Scottish Government in March 2026, recorded that funding had been agreed with it to take forward the recommendation (The action log, Mar 2026). In November 2025, she reported that an NHS England-led group addressing the recommendation had been disbanded due to funding constraints (Professor Emma Watson, Nov 2025). In May 2025, the UK Government stated that the General Medical Council accepted the recommendation and was reviewing training arrangements while four-nation work identified gaps to implement educational resources (Cabinet Office response, May 2025).
Inquiry Website Preservation
The Inquiry website is maintained online
In May 2025, the UK Government accepted the recommendation and stated that it was taking forward work to ensure the website is maintained with full functionality after the Inquiry closes (Cabinet Office response, May 2025). It noted that a standard transfer to The National Archives leads to lost search engine capacity, but work was underway to keep all uncovered information easily publicly available (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Duty of Candour - Northern Ireland
Duty of candour:
A statutory duty of candour in healthcare should be introduced in Northern Ireland.
The Inquiry recommended introducing a statutory duty of candour in healthcare across Northern Ireland. In September 2025, Mike Nesbitt, Minister of Health, stated in a written ministerial statement to the Northern Ireland Assembly that officials had been tasked with developing a bill for an organisational duty of candour during the current mandate (Mike Nesbitt, Sep 2025). Previously, in May 2025, the Northern Ireland Executive stated that it would advance an organisational duty first while considering an individual duty later, taking into account consultation findings and wider UK legislative work (Northern Ireland Executive response, May 2025).
Duty of Candour - Scotland and Wales Review
Duty of candour:
The operation of the duties of candour in healthcare in Scotland and in Wales should be reviewed, as it is being in England, to assess how effective its operation has been in practice. Since the duty was introduced in 2023 in Wales, the review there need not be immediate, but should be no later than the end of 2026.
The Inquiry recommended reviewing how healthcare duties of candour operate in Scotland and Wales. For Scotland, Lynne Nicol of the Scottish Government stated at a March 2026 meeting, in minutes published in May 2026, that its review was completed in December 2025 and a resulting programme of work is being developed for the new parliamentary term (Lynne Nicol, Mar 2026). For Wales, the Welsh Government stated in May 2025 that the duty introduced there in 2023 will be evaluated, with the recommendation integrated into a specification out to tender for an evaluation research programme (Welsh Government response, May 2025).
Duty of Candour - England Review
Duty of candour:
The review of the duty of candour currently under way in England should be completed as soon as practicable.
In May 2025, the UK Government accepted the recommendation, stating that although findings from a November 2024 call for evidence showed the statutory duty was "underwhelming in totality", completing the review remained outstanding while it prepared a response to a related consultation on manager regulation to inform the final report (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Individual Duty of Candour for Leaders
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.
In May 2025, the UK Government stated that it was preparing its response to a consultation, held between November 2024 and February 2025 on options for regulating NHS managers, which sought views on whether to introduce a professional duty of candour for NHS leaders and hold them accountable for organisational candour (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Leadership Accountability for Safety
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.
In May 2025, the UK Government accepted the recommendation in principle, stating that imposing personal accountability through secondary legislation is complex to implement and could be counter-productive to advancing a safety culture (Cabinet Office response, May 2025). It noted in May 2025 that it was preparing a response to a consultation on regulating managers and that the Department of Health and Social Care was consulting on an accountability pledge for the NHS Constitution (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Organisational Culture Change
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.
In its response presented to Parliament in May 2025, the UK Government stated that this recommendation on organisational culture change and leadership accountability for patient safety was accepted in principle alongside the Welsh Government, the Scottish Government and the Northern Ireland Executive (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Simplify External Regulation
Regulation:
That external regulation of safety in healthcare be simplified. As a first step towards this, there should be a UK wide review by the four health departments of the systems of external regulation, with the aim of addressing all the points made earlier in this Report and in other reports since 2000.
In May 2025, the UK Government stated that the Secretary of State for Health and Social Care had asked Dr Penny Dash to review patient safety across six core regulatory bodies to determine whether a different approach or delivery model could achieve greater value, adding that the review would be published shortly to inform its ten-year health plan and an NHS Quality Strategy (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Safety Management Systems Coordination
Regulation:
That the national healthcare administrations in England, Northern Ireland, Scotland and Wales explore, and if appropriate, support the development and implementation of safety management systems (“SMS”s) through SMS coordination groups (as recommended by the HSSIB), and do so as a matter of priority.
In May 2025, the UK Government accepted the recommendation, stating that NHS England had established a coordination group in 2023 to explore adapting safety management systems for healthcare (Cabinet Office response, May 2025). It added in that response that the group's work remained ongoing without reaching specific conclusions and was likely to report later in 2025 (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Patient Records Audit
Patient Records:
Before the end of 2027 there should be a formal audit, publicly reported, of the extent of success of digitisation of patient records in each of the four health jurisdictions of the UK, measuring at least the levels of patient access to their personal records, their ability to identify and correct apparent errors in them, their interoperability, and the confidence of health professionals in the detail, accuracy and timeliness of any record they enter, and that little material which should be recorded has been omitted. Next steps should be identified.
The Inquiry asked for a publicly reported audit of patient record digitisation by 2027. In minutes of a March 2026 meeting published in May 2026, Marion Logan of the Scottish Government stated that annual health board updates were being collected, a 2025 summary report was due, and Scotland would report on progress by late 2027 (Marion Logan, Mar 2026). In May 2025, the United Kingdom (UK) Government stated that National Health Service (NHS) England was using Digital Maturity Assessments to capture most audit elements for secondary care records, while planning how to capture professional views (Cabinet Office response, May 2025). In the same response, the Northern Ireland Executive stated that continuous monitoring meant a formal audit was not required, while the Welsh Government detailed work expanding records access through the NHS Wales App (Welsh Government response, May 2025; Northern Ireland Executive response, May 2025).
Cross-Administration Patient Safety Coordination
Coordination of patient records with devolved governments:
Consideration should be given by the national healthcare administrations in England, Scotland, Wales and Northern Ireland, to further coordination of their approaches particularly to ensure that patterns of harm, or trends, are identified and any response which for the sake of patient safety would be better coordinated than left to each individual administration can collaboratively be agreed and implemented.
In May 2025, the UK Government reported that the recommendation was "accepted in full by the UK Government, the Welsh Government, the Scottish Government and the Northern Ireland Executive", pointing to NHS England's Learn From Patient Safety Events service as a model for recording incidents and issuing safety alerts (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Civil Service Statutory Duty of Candour
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.
In May 2025, the UK Government accepted the recommendation in principle, stating that the Prime Minister had committed to introducing legislation for a statutory duty of candour with criminal sanctions for public authorities and public servants (Cabinet Office response, May 2025). It reported that it was consulting widely and drafting the bill ahead of its introduction to Parliament, while noting that an updated Ministerial Code had also been issued to emphasize openness and candour (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Monitoring Non-Statutory Duties
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.
In May 2025, the UK Government accepted the recommendation in principle, stating that the Prime Minister committed to introducing legislation for a statutory duty of candour covering public authorities and public servants, which will include criminal sanctions (Cabinet Office response, May 2025). It added that it was consulting widely and drafting the bill ahead of its introduction to Parliament (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Ministerial Duty of Candour
The Government should consider the extent to which Ministers should be subject to a duty beyond their current duty to Parliament under the Ministerial Code.
In May 2025, the UK Government accepted the recommendation in principle, stating that the Prime Minister had committed to delivering legislation for a statutory duty of candour with criminal sanctions covering public servants and authorities (Cabinet Office response, May 2025). It added in the same response that it was consulting widely and drafting a Hillsborough Law ahead of its introduction to Parliament, having already updated the Ministerial Code to emphasize candour (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Hepatologist Oversight and Fibroscan Access
All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care:
Those who have been diagnosed with cirrhosis at any point should receive lifetime monitoring by way of six-monthly fibroscans and annual clinical review, either nurse-led, consultant-led or, where appropriate, by a GP with a specialist interest in hepatitis
The Inquiry recommended lifetime six-monthly fibroscans and annual reviews for hepatitis cirrhosis patients. In May 2025, the UK Government stated that it accepted the recommendation, balancing implementation against clinical guidelines and equitable access (Cabinet Office response, May 2025). It described plans for consultant hepatologist oversight, a referral framework for fibroscans, and a new National Health Service (NHS) cirrhosis surveillance registry, though six-monthly fibroscans and annual reviews are not mentioned in the sources (Cabinet Office response, May 2025).
Specialist Hepatology Centre Access
All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care:
Those who have fibrosis should receive the same care
The Inquiry recommended that transfusion-infected hepatitis patients with fibrosis receive the same care. In May 2025, the UK Government stated that it accepted the recommendation, balancing implementation against National Health Service (NHS) England's role to promote equitable access and clinical guidelines (Cabinet Office response, May 2025). It noted that consultant hepatologists would oversee patient care, while a framework was being developed to identify individuals needing fibrosis staging and a cirrhosis surveillance registry would be introduced (Cabinet Office response, May 2025).
Uncertainty About Fibrosis
All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care:
Where there is any uncertainty about whether a patient has fibrosis they should receive the same care
The Inquiry recommended that hepatitis patients with uncertainty about fibrosis receive the same care. In May 2025, the UK Government accepted the recommendation, stating that implementation would be balanced against clinical guidelines and the principle that care should not depend on how infection was acquired (Cabinet Office response, May 2025). It noted that National Health Service (NHS) England is developing a framework to identify bleeding disorder patients lacking fibrosis staging to refer them for scans, alongside introducing a cirrhosis surveillance registry (Cabinet Office response, May 2025).
Fibroscan for Liver Imaging
All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care:
Fibroscan technology should be used for liver imaging, rather than alternatives
The Inquiry recommended that patients infected with hepatitis through blood receive Fibroscan liver imaging. In May 2025, the UK Government stated that it accepted the recommendation, though implementation would be balanced against clinical guidelines and equitable access across the National Health Service (NHS) (Cabinet Office response, May 2025). It noted that NHS England was developing a framework to enable referrals for Fibroscan testing for patients with bleeding disorders, while a cirrhosis surveillance registry remained to be introduced (Cabinet Office response, May 2025).
Consultant Hepatologist Access
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
The Inquiry recommended that patients infected with hepatitis C see a consultant hepatologist. In May 2025, the UK Government stated that all patients will have their care overseen by a consultant hepatologist, while balancing implementation against equitable access, practicability, and clinical guidelines (Cabinet Office response, May 2025). It reported that National Health Service (NHS) England had audited current pathways and was developing a framework alongside a cirrhosis surveillance registry to identify and monitor affected individuals (Cabinet Office response, May 2025).
Commissioning Hepatology Services
All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care:
Those bodies responsible for commissioning hepatology services in each of the home nations should publish the steps they have taken to satisfy themselves that the services they are commissioning meet the particular needs of the group of people harmed by NHS treatment
The Inquiry asked home nation hepatology commissioners to publish how services meet harmed patients' needs. In May 2025, the UK Government accepted the recommendation, stating it would balance implementation against equitable access, and reported that National Health Service (NHS) England had audited care pathways (Cabinet Office response, May 2025). It described developing a framework to identify exposed patients with bleeding disorders and introducing a cirrhosis surveillance registry, but publishing steps taken by commissioners across each home nation was not mentioned (Cabinet Office response, May 2025).
Transfusion Committees and Tranexamic Acid - England
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.
The Inquiry recommended surgical checklists and board reporting on tranexamic acid in England. In May 2025, the UK Government stated that an expert working group was considering plans to increase tranexamic acid use, though surgical checklists and board reporting were not mentioned, required funding had not yet been identified, and implementation would take several years (Cabinet Office response, May 2025). In June 2026, Sir Brian Langstaff, who chaired the inquiry, told the Public Administration and Constitutional Affairs Committee that discussions on tranexamic acid within the blood service were producing beneficial results, though these had not yet appeared publicly on the Cabinet Office dashboard (Sir Brian Langstaff, Jun 2026).
Tranexamic Acid - Scotland, Wales and NI
In Scotland, Wales and Northern Ireland offering the use of tranexamic acid should be considered a treatment of preference in respect of all eligible surgery.
The Inquiry asked Scotland, Wales, and Northern Ireland to prefer tranexamic acid for eligible surgery. Addressing Scotland, Dr Lorna McLintock of the Scottish National Blood Transfusion Service (SNBTS), as minuted by the Scottish Government in March 2026 and published in May 2026, reported that revised National Institute for Health and Care Excellence (NICE) guidance broadening the drug's scope was issued in February 2026 and circulated to hospital transfusion teams (Dr Lorna McLintock, Mar 2026). In May 2025, the Welsh Government reported that phased implementation across national programmes, including a surgical checklist incorporating the drug, was expected to conclude by 2026 (Welsh Government response, May 2025). Also in May 2025, the Northern Ireland Executive stated that health trusts were asked to ensure the treatment was offered while it sought assurance on current practice across the system (Northern Ireland Executive response, May 2025).
Transfusion Performance Benchmarking
Consideration be given to standardising and benchmarking transfusion performance between hospitals in order to deliver better patient blood management
In November 2025, Dr Lorna McLintock of the Scottish National Blood Transfusion Service reported that all Scottish health boards had confirmed using its clinical transfusion dashboard and that a UK-wide benchmarking group had been established (Dr Lorna McLintock, Nov 2025). Earlier, in May 2025, the UK Government accepted the recommendation, stating that it had initiated a review of benchmarking practices, requested updated guidance from the National Institute for Health and Care Excellence, and was working with the Care Quality Commission, though developing new benchmarking categories and funding to expand the model health dashboard were still required (Cabinet Office response, May 2025).
Transfusion 2024 Review Progress
Review of progress towards the Transfusion 2024 recommendations:
Progress in implementation of the Transfusion 2024 recommendations be reviewed, and next steps be determined and promulgated; and that in Scotland the 5 year plan is reviewed in or before 2027 with a view to determining next steps.
In March 2026, Dr Lorna McLintock of the Scottish National Blood Transfusion Service reported, in minutes published by the Scottish Government, that progressing a Scotland-wide transfusion strategy was paused while a new Chief Executive for Public Services Delivery Scotland is onboarded (Dr Lorna McLintock, Mar 2026). Earlier, in May 2025, the UK Government accepted the recommendation in principle, stating that progress against Transfusion 2024 had been reviewed by NHS England and NHS Blood and Transplant, with a full report expected in early 2025/26 to inform a wider Transfusion Transformation Strategy (Cabinet Office response, May 2025). The government noted that substantial funding would be required to design and deliver the transformation programme (Cabinet Office response, May 2025).
Transfusion Laboratory Staffing
Transfusion laboratories:
Transfusion laboratories should be staffed (and resourced) adequately to meet the requirements of their functions.
In March 2026, Dr Lorna McLintock of the Scottish National Blood Transfusion Service reported to the Scottish Government that a Strategic Needs Assessment for hospital blood banking had been completed and submitted to it for consideration (Dr Lorna McLintock, Mar 2026). Previously, the UK Government stated in May 2025 that work was ongoing to review staffing and build an evidence base, but noted that funding would be required to undertake full workforce modelling and develop minimum staffing level standards (Cabinet Office response, May 2025).
Training in Transfusion Medicine
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.
An action log minuted by the Scottish Government recorded in March 2026 that funding had been agreed with NHS Education for Scotland to take forward parts of the recommendation (The action log, Mar 2026). Previously, in November 2025, Professor Emma Watson reported to that oversight group that an NHS England-led group addressing the recommendation had been disbanded due to funding constraints (Professor Emma Watson, Nov 2025). In May 2025, the UK Government had accepted the recommendation in principle, noting that curricula were undergoing review but funding was needed to address training gaps (Cabinet Office response, May 2025).
Implementing SHOT Reports
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.
The Scottish Government reported in November 2025 that it had issued a Director letter and monitoring spreadsheet regarding recommendation 7(e) to NHS Board Medical Directors in August 2025, requesting that boards return the completed template by February 2026 (The Scottish Government action log, Nov 2025). Earlier, the UK Government stated in May 2025 that work was underway to develop governance practices for implementing Serious Hazards of Transfusion recommendations (Cabinet Office response, May 2025). It added that accreditation for SHOT to issue patient safety alerts through the Central Alerting System remained under consideration and dependent on funding, while SHOT was developing safety standards for NHS provider organisations (Cabinet Office response, May 2025).
Transfusion Outcome Framework
Establishing the outcome of every transfusion:
That a framework be established for recording outcomes for recipients of blood components. That those records be used by NHS bodies to improve transfusion practice (including by providing such information to haemovigilance bodies). Success in achieving this will be measured by the extent to which the SHOT reports for the previous three years show a progressive reduction in incidents of incorrect blood component transfusions measured as a proportion of the number of transfusions given.
The Inquiry called for a framework to record and monitor blood transfusion recipient outcomes. In May 2025, the UK Government stated that implementation requires substantial cross-nation investment, with a design team mapping clinical pathways, digitisation requirements, and standards (Cabinet Office response, May 2025). In the same month, the Scottish Government reported work to adapt its Account for Blood system, while the Welsh Government noted it had established a digital working group and roadmap (Scottish Government response, May 2025; Welsh Government response, May 2025). The Northern Ireland Executive stated in May 2025 that regional electronic pathology and tracking systems were being developed, alongside work to assess how far the recommendation is already being carried out (Northern Ireland Executive response, May 2025). The record holds nothing dated later than the response of May 2025 (Northern Ireland Executive response, May 2025).
NHSBT Transfusion Outcome Funding
Establishing the outcome of every transfusion:
To the extent that the funding for digital transformation does not already cover the setting up and operation of this framework, bespoke funding should be provided.
The Inquiry recommended bespoke funding to establish the outcome of every blood transfusion. In May 2025, the UK Government stated that implementation requires substantial investment across the four nations, reporting that a design team is mapping clinical pathways, digitisation requirements, and standards (Cabinet Office response, May 2025). It noted that interdependencies still need to be mapped against other large digital systems (Cabinet Office response, May 2025). In the same month, the Scottish Government, Welsh Government, and Northern Ireland Executive each outlined regional work to identify digital gaps, map programme costs, and integrate electronic transfusion tracking systems (Scottish Government response, May 2025; Welsh Government response, May 2025; Northern Ireland Executive response, May 2025). The record holds nothing dated later than the response of May 2025 (Northern Ireland Executive response, May 2025).
Blood Tracking Systems Funding
Establishing the outcome of every transfusion:
That funding for the provision of enhanced electronic clinical systems in relation to blood transfusion be regarded as a priority across the UK.
The Inquiry recommended prioritising funding across the United Kingdom (UK) for enhanced electronic transfusion systems. In May 2025, the UK Government stated that implementation requires substantial investment across the four nations, reporting that a design team is mapping clinical pathways, digitisation requirements, and standards (Cabinet Office response, May 2025). It noted that interdependencies with other large digital initiatives and systems must still be mapped (Cabinet Office response, May 2025). In the same month, the Scottish Government, Welsh Government, and Northern Ireland Executive outlined regional work to update tracking systems, prepare business cases, and develop digital roadmaps (Scottish Government response, May 2025; Welsh Government response, May 2025; Northern Ireland Executive response, May 2025). The record holds nothing dated later than the response of May 2025 (Northern Ireland Executive response, May 2025).
Pre-1996 Transfusion Testing
When doctors become aware that a patient has had a blood transfusion prior to 1996, that patient should be offered a blood test for Hepatitis C.
The Inquiry recommended offering Hepatitis C tests to patients who had pre-1996 blood transfusions. In May 2025, the UK Government accepted the recommendation, stating that changes to the General Practice (GP) Online Registration service were ready to launch at the end of that month alongside supporting NHS England guidance (Cabinet Office response, May 2025). In the same month, the Scottish Government and the Welsh Government both reported issuing clinical circulars asking healthcare staff to question patients about previous transfusions and offer testing (Scottish Government response, May 2025; Welsh Government response, May 2025). The Northern Ireland Executive reported in May 2025 that circular guidance had been issued, while engagement remained ongoing to determine the registration approach for primary care (Northern Ireland Executive response, May 2025). The record holds nothing dated later than the response of May 2025 (Northern Ireland Executive response, May 2025).
New Patient Registration Screening
As a matter of routine, new patients registering at a practice should be asked if they have had such a transfusion.
The Inquiry recommended routinely asking newly registered patients whether they have had a blood transfusion. In May 2025, the UK Government stated that it accepted the recommendation, noting that changes to the General Practitioner (GP) Online Registration service had been agreed for national rollout at the end of that month alongside supporting NHS England guidance (Cabinet Office response, May 2025). The Scottish Government and the Welsh Government reported in May 2025 that they had issued circulars directing primary care staff to ask new patients about previous blood transfusions (Scottish Government response, May 2025; Welsh Government response, May 2025). The Northern Ireland Executive stated in May 2025 that engagement remained ongoing with primary care policy leads to determine the best approach for general practice registration (Northern Ireland Executive response, May 2025). The record holds nothing dated later than the response of May 2025 (Northern Ireland Executive response, May 2025).
Haemophilia Peer Review
That peer review of haemophilia care should continue to occur as presently practised, with any necessary support being provided by NHS Trusts and Health Boards;
The Inquiry recommended that peer review of haemophilia care continue with health service support. In April 2026, Parliamentary Under-Secretary of State at the Department of Health and Social Care Dr Zubir Ahmed stated that a five-year peer review cycle continues and a final report is expected imminently, alongside planned letters seeking commitment from local boards and an updated service specification undergoing final approvals following public consultation (Dr Zubir Ahmed, Apr 2026). In May 2025, the UK Government stated that the revised service specification was intended to proceed to public consultation that summer (Cabinet Office response, May 2025).
Trust/Board Action on Peer Reviews
That NHS Trusts and Health Boards should be required to deliberate on peer review findings and give favourable consideration to implementing the changes identified with a view to ensuring comprehensive, safe, care.
The Inquiry recommended that trusts and health boards act upon peer review findings. In April 2026, Dr Zubir Ahmed, Parliamentary Under-Secretary of State at the Department of Health and Social Care, stated that a revised Haemophilia Service Specification requiring providers to act upon peer review findings was undergoing final approvals (Dr Zubir Ahmed, Apr 2026). The Minister added that publication of the final peer review report was expected imminently, alongside a letter asking integrated care boards and trust boards to confirm their commitment to implement findings (Dr Zubir Ahmed, Apr 2026). While the update described action regarding trust boards, health boards were not mentioned (Dr Zubir Ahmed, Apr 2026).
Five-Year Peer Review Cycle
A peer review of each centre should take place not less than once every five years.
The Inquiry recommended that each haemophilia centre undergo peer review at least every five years. In April 2026, Dr Zubir Ahmed, Parliamentary Under-Secretary of State at the Department of Health and Social Care, stated that a formal five-year peer review cycle has operated since 2019 (Dr Zubir Ahmed, Apr 2026). The Minister added that publication of the final peer review report was expected imminently, while a revised service specification contractually requiring providers to participate was undergoing final approvals (Dr Zubir Ahmed, Apr 2026).
Haemophilia Centre Resources
The necessary administrative and clinical resources should be provided by hospital trusts and boards, integrated care boards, and service commissioners to facilitate multi-disciplinary regional networks to discuss policy and practice in haemophilia and other inherited bleeding disorders care, provided they involve patients in their discussions.
In April 2026, Dr Zubir Ahmed, Parliamentary Under-Secretary of State at the Department of Health and Social Care, stated that work was in progress and that NHS England had drafted a proposed National Clinical Network Specification to establish multi-disciplinary regional networks (Dr Zubir Ahmed, Apr 2026). The Minister reported in that April 2026 response that the specification remains dependent on additional funding, which the UK Government previously noted in May 2025 had not yet been identified (Cabinet Office response, May 2025; Dr Zubir Ahmed, Apr 2026).
Recombinant Products Over Plasma-Derived
Recombinant coagulation factor products should be offered in place of plasma-derived ones where clinically appropriate. Service commissioners should ensure that such treatment decisions are funded accordingly.
In April 2026, Parliamentary Under-Secretary of State for Health and Social Care Dr Zubir Ahmed stated that all conditions with non-plasma alternatives are now addressed by commissioning policies or funding agreements, though funding required to implement a clinical policy for recombinant Von Willebrand factor prophylaxis across all ages has not yet been identified (Dr Zubir Ahmed, Apr 2026). The UK Government previously reported in May 2025 that NHS England had commenced funding recombinant Von Willebrand factor for managing bleeding episodes and surgical pre-treatment in August 2024 (Cabinet Office response, May 2025).
National Haemophilia Database Support
That the National Haemophilia Database, run by the UKHCDO, merits the support of additional central funding.
In an April 2026 parliamentary answer, Parliamentary Under-Secretary of State at the Department of Health and Social Care Dr Zubir Ahmed stated that NHS England provides approximately 40% of the National Haemophilia Database's annual costs and continues to work with the United Kingdom Haemophilia Centres Doctors' Organisation to assess requirements for increased funding (Dr Zubir Ahmed, Apr 2026). The Minister noted in April 2026 that while stakeholders agreed the registry remains immensely valuable for clinical care, further progress is subject to additional funding that "has not yet been identified" (Dr Zubir Ahmed, Apr 2026).
Patient Satisfaction in Clinical Audits
A clinical audit should as a matter of routine include measures of patient satisfaction or concern, and these should be reported to the board of the body concerned. Success in this will be measured by comparing the measure of satisfaction from one year to the next, such that the reports to the board concerned demonstrate a trend of improvement by comparing this year’s outcomes with the similar outcomes from at least the two previous years.
The UK Government accepted the recommendation in principle in May 2025, stating that NHS England was reviewing clinical audits to clarify gaps in patient involvement and satisfaction reporting (Cabinet Office response, May 2025). It noted in May 2025 that this work involves interdependencies with wider patient voice strategies and policy developments that require careful consideration (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Charity Funding for Patient Advocacy
That the following charities receive funding specifically for patient advocacy: the UK Haemophilia Society; the Hepatitis C Trust; Haemophilia Scotland; the Scottish Infected Blood Forum; Haemophilia Wales; Haemophilia Northern Ireland; and the UK Thalassaemia Society.
In July 2025, Paymaster General and Minister for the Cabinet Office Nick Thomas-Symonds stated that the Department for Health and Social Care was re-examining advocacy funding for that year and exploring options for the future after charities raised issues regarding their allocations (Nick Thomas-Symonds, Jul 2025). The UK Government had previously announced in May 2025 that £500,000 would be provided across named charities, with meetings taking place to determine individual grant awards (Cabinet Office response, May 2025).
Additional Charity Support
That favourable consideration be given to other charities and organisations supporting people infected and affected that were granted core participant status (as listed on the Inquiry website) to continue to provide support for at least the next 18 months. Further support should be reviewed at that stage with a view to it continuing as appropriate.
The Inquiry recommended continued support for core participant organisations helping infected and affected individuals. In May 2025, the UK Government stated that "consideration is being given as to how to best support organisations and charities" covered by this recommendation (Cabinet Office response, May 2025). It affirmed that it remained committed to supporting these organisations as appropriate (Cabinet Office response, May 2025). The recommendation's provisions for at least 18 months of support and a subsequent review were not mentioned in the response (Cabinet Office response, May 2025). The record holds nothing dated later than the response of May 2025 (Cabinet Office response, May 2025).
Thalassaemia Society Support
Particular consideration be given, together with the UK Thalassaemia Society and the Sickle Cell Society, to how the needs of patients with thalassaemia or sickle cell disease can best holistically be addressed.
The Inquiry recommended addressing the holistic needs of thalassaemia and sickle cell disease patients collaboratively. In May 2025, the UK Government stated that National Health Service (NHS) England established a programme reviewing care pathways and created advisory groups to work with the UK Thalassaemia Society and the Sickle Cell Society (Cabinet Office response, May 2025). It noted that while initial funding supports acute crisis care, additional funding needed to fully implement the programme has not yet been identified (Cabinet Office response, May 2025). Also in May 2025, the Scottish Government reported engaging networks under its Rare Disease Action Plan, the Welsh Government outlined existing hereditary anaemia services, and the Northern Ireland Executive reported exploring screening options while using London specialists (Scottish Government response, May 2025; Welsh Government response, May 2025; Northern Ireland Executive response, May 2025). The record holds nothing dated later than the response of May 2025 (Northern Ireland Executive response, May 2025).
Yellow Card System Prominence
Steps be taken to give greater prominence to the online Yellow Card system to those receiving drugs or biological products, or who are being transfused with blood components.
In May 2025, the UK Government accepted the recommendation, stating that the Medicines and Healthcare Regulatory Agency had begun regional awareness workshops and that Yellow Card platform changes were undergoing user acceptance testing for delivery by September 2025 (Cabinet Office response, May 2025). It noted in May 2025 that a scoping meeting for final delivery of the changes was to be arranged alongside further promotional activities (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Ministerial Power to Call Inquiries
That a minister should retain the power to call an inquiry as the minister sees fit, in accordance with the Inquiries Act 2005 – but where a minister does not choose to do so, then:
The Inquiry recommended ministers retain powers to call inquiries, with alternatives if they decline. The UK Government stated in May 2025 that Parliament must decide whether to adopt the recommendation, adding that if the recommendation is adopted, it accepts its obligation to publish detailed reasons when disagreeing with establishing an inquiry (Cabinet Office response, May 2025). In March 2026, Sir Brian Langstaff, Chair of the Inquiry, welcomed its acceptance in principle and commitment to provide a further update to Parliament (Sir Brian Langstaff, Mar 2026).
Parliamentary Referral to PACAC
If there is sufficient support from within Parliament for there to be an inquiry, the question whether there should be one should be referred to PACAC for it to consider the question.
The Inquiry recommended referring supported inquiry proposals to the Public Administration and Constitutional Affairs Committee. In May 2025, the UK Government stated that it was for Parliament to decide whether to accept the recommendation and how to fulfil it alongside existing scrutiny mechanisms (Cabinet Office response, May 2025). In March 2026, Sir Brian Langstaff, Chair of the Infected Blood Inquiry, welcomed the Government's acceptance in principle of the recommendation and its commitment to provide a further update to Parliament (Sir Brian Langstaff, Mar 2026).
PACAC Recommendation Power
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 Inquiry recommended that the Public Administration and Constitutional Affairs Committee propose public inquiries. In May 2025, the UK Government stated that select committees already possess scrutiny powers, noting that Parliament must decide whether to accept the proposal alongside its existing mechanisms (Cabinet Office response, May 2025). In March 2026, Sir Brian Langstaff, Chair of the Infected Blood Inquiry, welcomed the Government's acceptance in principle and its commitment to provide a further update to Parliament (Sir Brian Langstaff, Mar 2026).
Ministerial Reasons for Disagreement
If the minister disagrees with the recommendation, they must set out in detail and publish reasons for this disagreement which are sufficient to satisfy PACAC that the matter has been carefully and properly considered.
The Inquiry recommended that ministers publish detailed reasons if they disagree with a recommendation. The UK Government stated in May 2025 that if Parliament adopts the recommendation, it accepts its obligation to publish detailed reasons when disagreeing with a proposal to establish an inquiry, and committed to update Parliament on wider inquiry reforms, though satisfying the Public Administration and Constitutional Affairs Committee (PACAC) was not mentioned (Cabinet Office response, May 2025). In March 2026, Sir Brian Langstaff, Chair of the Infected Blood Inquiry, welcomed the Government's acceptance in principle and its commitment to provide a further update (Sir Brian Langstaff, Mar 2026).
Implementation Commitment Within 12 Months
Within the next 12 months, the Government should consider and either commit to implementing the recommendations which I make, or give sufficient reason, in sufficient detail for others to understand, why it is not considered appropriate to implement any one or more of them.
During that period, and before the end of this year – the Government should report back to Parliament as to the progress made on considering and implementing the recommendations.
This timetable should not interfere with earlier consideration and response to the Recommendations of the Second Interim Report of the Inquiry.
The UK Government stated in its May 2025 response, presented to Parliament by the Minister for the Cabinet Office, that its comprehensive document on the implementation of the recommendations by all of the UK's administrations replaced its December 2024 update and fulfilled the obligations set out in recommendation 12a (Cabinet Office response, May 2025; Cabinet Office, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
Parliamentary Progress Report
During that period, and before the end of this year – the Government should report back to Parliament as to the progress made on considering and implementing the recommendations.
The UK Government stated in its formal response of May 2025, presented to Parliament by the Minister for the Cabinet Office, that its December 2024 parliamentary update fulfilled the obligations set out in this recommendation, and it recorded the recommendation's delivery status as completed (Cabinet Office response, May 2025; Cabinet Office, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025; Cabinet Office, May 2025).
No Delay to Second Interim Response
This timetable should not interfere with earlier consideration and response to the Recommendations of the Second Interim Report of the Inquiry.
In May 2025, the UK Government accepted the recommendation, stating that detail set out under recommendation 1 met its formal obligation to respond to the Second Interim Report, alongside its August 2024 summary of the Infected Blood Compensation Scheme (Cabinet Office response, May 2025). It noted that its position on compensation was also informed by parliamentary debate and community engagement led by Sir Robert Francis (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).
PACAC Oversight of Implementation
The Public Administration and Constitutional Affairs Committee (“PACAC”) should review both the progress towards responding to the Inquiry’s recommendations and, to the extent that they are accepted, implementing those recommendations.
The Inquiry asked that a parliamentary committee review progress on responding to and implementing recommendations. Nick Thomas-Symonds, Paymaster General and Minister for the Cabinet Office, stated to the House of Commons in July 2025 that he had asked the Public Administration and Constitutional Affairs Committee (PACAC) to scrutinise implementation of recommendations, describing action on implementation but not on progress towards responding to recommendations (Nick Thomas-Symonds, Jul 2025). Sir Brian Langstaff, Chair of the Infected Blood Inquiry, stated in oral evidence to the committee in June 2026 that following up recommendations was a role for a body such as the committee rather than an inquiry itself (Sir Brian Langstaff, Jun 2026). The Minister stated that it is for the committee to outline how it will approach that work (Nick Thomas-Symonds, Jul 2025).
PACAC Role for Future Inquiries
PACAC should accept the role in respect of any future statutory inquiry of reviewing government’s timetable for consideration of recommendations, and of its progress towards implementation of that inquiry’s recommendations.
The Inquiry asked the Public Administration and Constitutional Affairs Committee to review future inquiry recommendations. In May 2025, the UK Government stated that it accepted the principles behind the proposal, noting that the role is for Parliament to consider (Cabinet Office response, May 2025). It added that it is actively considering wider inquiry reforms, including examining how to ensure effective transparency and accountability around recommendation responses and implementation (Cabinet Office response, May 2025). It stated that it will provide updates as this work progresses and publish progress on an accessible dashboard in due course (Cabinet Office response, May 2025). The record holds nothing dated later than the response of May 2025 (Cabinet Office response, May 2025).