Recommendation IBI-7f(i): Transfusion Outcome Framework
From Infected Blood Inquiry Final Report, published 20 May 2024.
Recommendation
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.
In brief (written by this site)
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).
Sources
AI-generated summary of the record on this page, checked by a second model and automatic checks, 5 Oct 2026. The record below is the sources' own words.
About this summary
This recommendation applies across many organisations. The record reflects central policy activity; adoption in individual organisations may vary.
Government response
As part of an extensive programme of transformation and modernisation of the Health and Social Care System (HSC) in Northern Ireland, the Pathology Blueprint Programme, a new regional pathology management structure, will provide a digital roadmap and the introduction of digital interoperability across the whole local system and digitalisation of pathology services through three electronic systems for blood transfusions: on the clinical side, a regional Electronic Patient Record (EPR) will create a single digital care record for every citizen in Northern Ireland who receives health and social care; for laboratories and blood banks, the WinPath Core Laboratory Information Management System (LIMS) will significantly improve the delivery of key clinical diagnostic services; and the new Blood Production and Tracking (BPaT) solution will integrate blood production and tracking information to provide a fully functioning regional electronic vein-to-vein donor management, blood production and tracking system.
Once fully developed and integrated, these solutions will lead to an improved ability to ascertain patient outcomes for those receiving a transfusion, and will be paramount in providing one safe effective interface for clinical staff to ensure the right blood goes to the right patient. Moreover, service users will have access to all the relevant pathology data, including blood transfusion outcomes.
The Department of Health is currently engaging with Data Management colleagues within the Department and HSC Trusts to assess the extent to which this recommendation is already being carried out amid these ongoing developments.
A Digital working group consisting of Welsh Government officials, Welsh Blood Service, BHNOG and Digital Health & Care Wales (DHCW) has been established and has developed a roadmap outlining the interdependencies of current national IT programmes to meet this recommendation in full including timelines and costing required. Data accessibility to allow monitoring and benchmarking via the National Data Resource (NDR) is also underway, this work is supported through a proof of concept for clinical benchmarking within a data dashboard for Preoperative anaemia management for major surgery that will include red cell transfusions.
The existing ‘Account for Blood’ system already helps Scottish Health Boards to monitor outcomes for transfusion patients. SNBTS is working with its digital colleagues in NHS National Services Scotland (NSS), with help from the Haematology and Transfusion clinical network, to amend this system to ensure it can deliver the key elements envisaged by recommendation 7f) i. Separately the Scottish Government is working with SNBTS and NSS, with help from the Haematology and Transfusion clinical network, to help identify the gaps in current digital systems provision in the transfusion process within the Health Boards. This will then be developed into an outline business case to consider the most appropriate options for digitisation, which will be discussed in detail with all the Health Boards.
Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners.
To support an effective long term implementation plan that minimises complexity, a design team is currently undertaking mapping of clinical pathways, the requirements of digitisation along the pathway, interoperability and the employment of standards. Careful consideration needs to be given to the digital maturity of local organisations. Interdependencies will need to be mapped against other large digital initiatives and systems to be implemented.
Delivery
No statement on delivery from UK Government has been found in the sources searched (last checked 11 June 2026). This is separate from the response above.
Responsible bodies
Themes and tags
Who has spoken
- Northern Ireland Executive
Response - Welsh Government
Response - Scottish Government
Response - UK Government
Response