Public Inquiry Recommendations

IBI-A-4a Accepted in part

Infected Blood Inquiry (2025)

Interferon Treatment Impacts

People infected with Hepatitis B or C who have received a course of treatment with or based on interferon should be recognised as entitled to core awards at Level 3.

IBI-A-4b Accepted in part

Infected Blood Inquiry (2025)

Special Category Mechanism

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 …

IBI-A-5a Accepted in part

Infected Blood Inquiry (2025)

Severe Psychological Harm

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 …

IBI-A-6a Accepted in part

Infected Blood Inquiry (2025)

Financial Loss and Care

"x" be removed from the equation set out in Regulation 7.

IBI-A-6b Accepted in part

Infected Blood Inquiry (2025)

Exceptional Loss Evidence

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 …

IBI-A-7a Accepted in part

Infected Blood Inquiry (2025)

Unethical Research Award

Where there is evidence that an individual was the victim of unethical research practices IBCA should be authorised to make an unethical research practices award to that individual.

IBI-A-7b Accepted in part

Infected Blood Inquiry (2025)

Wider Definition of Unethical Research

When considering the evidence IBCA applies the wider definition of research explained in the Infected Blood Inquiry Additional Report chapter on Unethical Research.

IBI-A-8a Accepted in part

Infected Blood Inquiry (2025)

Supplementary Route for Affected Persons

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 …

IBI-4a(iv) Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-4a(v) Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-4b Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-4d Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-5a Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-5b Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-5c Accepted in part

Infected Blood Inquiry (2024)

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.

IBI-6a(ii) Accepted in part

Infected Blood Inquiry (2024)

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

IBI-6a(v) Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-7a(i) Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-7a(ii) Accepted in part

Infected Blood Inquiry (2024)

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.

IBI-7b Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-7c Accepted in part

Infected Blood Inquiry (2024)

Transfusion Laboratory Staffing

Transfusion laboratories: Transfusion laboratories should be staffed (and resourced) adequately to meet the requirements of their functions.

IBI-7d Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-7e Accepted in part

Infected Blood Inquiry (2024)

Implementing SHOT Reports

Implementing SHOT reports: That all NHS organisations across the UK have a mechanism in place for implementing recommendations of SHOT reports, which should be professionally mandated, and for monitoring such …

IBI-7f(i) Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-7f(ii) Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-7f(iii) Accepted in part

Infected Blood Inquiry (2024)

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.

IBI-9b Accepted in part

Infected Blood Inquiry (2024)

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, …

IBI-9c Accepted in part

Infected Blood Inquiry (2024)

Five-Year Peer Review Cycle

A peer review of each centre should take place not less than once every five years.

IBI-9d Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-9e Accepted in part

Infected Blood Inquiry (2024)

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.

IBI-9f Accepted in part

Infected Blood Inquiry (2024)

National Haemophilia Database Support

That the National Haemophilia Database, run by the UKHCDO, merits the support of additional central funding.

IBI-10a(i) Accepted in part

Infected Blood Inquiry (2024)

Patient Satisfaction in Clinical Audits

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 …

IBI-10a(iv) Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-11a Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-11b Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-11c Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-11d Accepted in part

Infected Blood Inquiry (2024)

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 …

IBI-12d Accepted in part

Infected Blood Inquiry (2024)

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.

IBI-12e Accepted in part

Infected Blood Inquiry (2024)

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.