Public Inquiry Recommendations

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.

- The Government's implementation dashboard records this recommendation as: Accepted in principle by the UK Government, Scottish Government, Welsh Government, Northern Ireland Executive (Infected Blood …

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 …

- The Government's implementation dashboard records this recommendation as: Accepted in principle by the UK Government, Scottish Government, Welsh Government, Northern Ireland Executive (Infected Blood …

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 Serious Hazard of Transfusion (SHOT) reports, which should be professionally mandated, …

- The Government's implementation dashboard records this recommendation as: Accepted in principle by the UK Government, Scottish Government, Welsh Government, Northern Ireland Executive (Infected Blood …

IBI-7f(i) Accepted

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 …

- The Government's implementation dashboard records this recommendation as: Accepted in principle by the UK Government, Welsh Government and Northern Ireland Executive. Accepted in full …

IBI-7f(ii) Accepted

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 …

- The Government's implementation dashboard records this recommendation as: Accepted in principle by the UK Government, Welsh Government and Northern Ireland Executive. Accepted in full …

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.

- The Government stated in December 2024 that enhanced electronic clinical systems for blood transfusion were part of the broader digital transformation programme, but that …

IBI-8a Accepted

Infected Blood Inquiry (2024)

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 Government's implementation dashboard records this recommendation as: Accepted in full by the UK Government, Scottish Government and Welsh Government. Accepted in principle by …

IBI-8b Accepted

Infected Blood Inquiry (2024)

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 Government's implementation dashboard records this recommendation as: Accepted in full by the UK Government, Scottish Government and Welsh Government. Accepted in principle by …

IBI-9a Accepted

Infected Blood Inquiry (2024)

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 Government's implementation dashboard records this recommendation as: Accepted in full by the UK Government, Scottish Government and Welsh Government. Accepted in principle by …

IBI-9b Accepted

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, …

- The Government's implementation dashboard records this recommendation as: Accepted in principle by the UK Government, Welsh Government and Northern Ireland Executive. Accepted in full …

IBI-9c Accepted

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.

- The Government's implementation dashboard records this recommendation as: Accepted in principle by the UK Government, Welsh Government and Northern Ireland Executive. Accepted in full …

IBI-9d Accepted

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 …

- The Government's implementation dashboard records this recommendation as: Accepted in principle by the UK Government, Welsh Government and Northern Ireland Executive. Accepted in full …

IBI-9e Accepted

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.

- The Government's implementation dashboard records this recommendation as: Accepted in principle by the UK Government, Welsh Government and Northern Ireland Executive. Accepted in full …

IBI-9f Accepted

Infected Blood Inquiry (2024)

National Haemophilia Database Support

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

- The Government's implementation dashboard records this recommendation as: Accepted in principle by the UK Government, Welsh Government and Northern Ireland Executive. Accepted in full …

IBI-10a(i) Accepted

Infected Blood Inquiry (2024)

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 …

- The Government's implementation dashboard records this recommendation as: Accepted in principle by the UK Government and the Northern Ireland Executive. Accepted in full by …

IBI-10a(ii) Accepted

Infected Blood Inquiry (2024)

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; …

- The Government's implementation dashboard records this recommendation as: Accepted in full by the UK Government and the Scottish Government. Accepted in principle by the …

IBI-10a(iii) Accepted

Infected Blood Inquiry (2024)

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 …

- The Government's implementation dashboard records this recommendation as: Accepted in full by the UK Government. Accepted in principle by the Scottish Government, the Welsh …

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 …

- The Government stated in December 2024 that NHS England had established a comprehensive programme to prioritise reduction of clinical risk, increase community support and …

IBI-10a(v) Accepted

Infected Blood Inquiry (2024)

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.

- The Government stated in December 2024 that the Yellow Card system was UK-wide and provided vital feedback, and that the MHRA was consulting on …

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 …

- The Government stated in December 2024 that it accepted the principles behind this recommendation and noted the broader debate about the effectiveness and reform …

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 the Public Administration and Constitutional …

- The Government stated in December 2024 that it accepted the principles behind this recommendation, and noted that the question of whether PACAC should 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 …

- The Government stated in December 2024 that it accepted the principles behind this recommendation regarding PACAC's potential role in recommending public inquiries (Government Response …

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 …

- The Government stated in December 2024 that it accepted the principles behind this recommendation regarding the requirement for ministers to publish detailed reasons for …

IBI-12a Accepted Urgent

Infected Blood Inquiry (2024)

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, …

- The Government published its response to the Infected Blood Inquiry's recommendations on 17 December 2024, within the 12 months recommended from the May 2024 …

IBI-12b Accepted Urgent

Infected Blood Inquiry (2024)

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 Government reported to Parliament on progress on 17 December 2024 by publishing its response to the Inquiry's recommendations, within the recommended deadline of …

IBI-12c Accepted Urgent

Infected Blood Inquiry (2024)

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.

- The Government's December 2024 response addressed the final report recommendations separately from the Second Interim Report recommendations, which had been implemented through the Victims …

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.

- The Government stated in December 2024 that it accepted the principles behind this recommendation, noting that it was for Parliament to consider, and referenced …

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 the government’s timetable for consideration of recommendations, and of its progress towards implementation of that inquiry’s …

- The Government stated in December 2024 that it accepted the principles behind this recommendation regarding PACAC's role in future inquiry follow-up, noting it was …

IR1-1 Accepted Urgent

Infected Blood Inquiry (2022)

Interim Compensation Payments

An interim payment, of no less than £100,000, should be paid to all those infected and all bereaved partners currently registered with any of the four UK infected blood support …

- The Victims and Prisoners Act 2024 received Royal Assent on 24 May 2024, establishing the Infected Blood Compensation Authority (IBCA) in Part 3 (Victims …

IR2-1 Accepted Urgent

Infected Blood Inquiry (2023)

Scheme Eligibility - Infected and Affected Persons

I recommend that the scheme should offer redress to those infected with HCV and/or HIV, and/or HBV (limited to chronic HBV unless the infection has resulted in a fatality in …

- The Victims and Prisoners Act 2024 Part 3 established the infected blood compensation scheme covering persons infected with HCV, HIV, and/or HBV and defined …

IR2-2 Accepted

Infected Blood Inquiry (2023)

Eligibility Conditions for Infected Persons

I recommend that the conditions of eligibility for admission of relevant infected persons to the scheme should be that: a) they have been diagnosed as being infected with one or …

- The Infected Blood Compensation Scheme regulations define eligibility conditions including diagnosis of HCV, HIV, or chronic HBV attributable to NHS blood or blood products, …

IR2-3 Accepted

Infected Blood Inquiry (2023)

Standard of Proof and Automatic Eligibility

As above, save that (a) the last bullet point should read: "eligibility is accepted if the information available points towards eligibility and the opposite cannot be shown to be more …

- The Government stated in December 2024 that the scheme had been designed to minimise the burden on applicants whilst protecting public funds, and that …

IR2-4 Accepted

Infected Blood Inquiry (2023)

Affected Persons Categories

I recommend that the following relevant affected persons should be admitted to the scheme: a) spouses, civil partners and long term cohabitees (for at least one year in the case …

- The Infected Blood Compensation Scheme regulations define eligible affected persons including spouses, civil partners, long-term cohabitees, children, parents, siblings, and carers of eligible infected …

IR2-5 Accepted

Infected Blood Inquiry (2023)

Classification of Infections and Severity

I recommend that infections eligible for compensation should be classified in the following manner: a) there should be defined categories for each type of eligible infection, and the stages through …

- The Infected Blood Compensation Scheme regulations establish a tariff-based classification system with defined severity levels for each type of eligible infection, including progression stages …

IR2-6 Accepted

Infected Blood Inquiry (2023)

Categories of Loss and Award Heads

I recommend that the appropriate award in any case should be composed under the following categories of loss, applicable to both eligible infected and affected persons: a) an Injury Impact …

- The Infected Blood Compensation Scheme regulations establish five award categories: Injury Impact Award, Social Impact Award, Autonomy Award, Care Award, and Financial Loss Award …

IR2-7 Accepted

Infected Blood Inquiry (2023)

No Exemplary Damages but Court Access Preserved

I recommend that there should be no award for exemplary damages, though it should remain open to a claimant to pursue such a claim in the courts irrespective of whether …

- The Infected Blood Compensation Scheme regulations provide a tariff-based assessment approach with a Core Route for standard assessments and a Supplementary Route for cases …

IR2-8 Accepted

Infected Blood Inquiry (2023)

Tariff-Based Compensation Framework

I recommend that the Government should approve a scheme setting out a framework of tariff based compensation for eligible infected and affected persons, at rates which broadly take account of …

- The Infected Blood Compensation Scheme regulations define award categories for affected persons including the Social Impact Award and provisions for bereaved partners, children, parents, …

IR2-9 Accepted

Infected Blood Inquiry (2023)

Status of Awards and Legal Rights

I recommend that, with reference to the status of awards: a) eligible infected and affected persons should not be required to accept the offer of an award in full and …

- The Government stated in December 2024 that acceptance of an award does not require applicants to waive their right to pursue litigation, and in …

IR2-10 Accepted

Infected Blood Inquiry (2023)

Form of Awards - Lump Sum and Periodical Payments

I recommend that: a) awards should be made in a lump sum in respect of an Injury Impact Award, Social Impact Award, Autonomy Award, and an award to compensate for …

- The Infected Blood Compensation Scheme regulations provide for lump sum payments for Injury Impact, Social Impact, Autonomy, and past Care and Financial Loss awards, …

IR2-11 Accepted

Infected Blood Inquiry (2023)

Interest on Past Losses

I recommend that interest be payable on awards for past financial losses and past provision of care, from the date of infection to the date of the award, in accordance …

- The Government stated in December 2024 that the compensation scheme aligns with the spirit of this recommendation and uses the GDP deflator to uplift …

IR2-12 Accepted Urgent

Infected Blood Inquiry (2023)

Interim Payments for Bereaved Families

I recommend that an interim payment of £100,000 should be paid to recognise the deaths of people to date unrecognised and alleviate immediate suffering. This should be done as follows: …

- The Government stated in December 2024 that interim payments of £100,000 had been made to estates of deceased infected persons and to bereaved families …

IR2-13 Accepted

Infected Blood Inquiry (2023)

Relationship with Support Schemes and Benefits

I recommend that, with regard to the relationship between compensation, support payments and benefits: a) in assessing compensation under the scheme, no account should be taken of any past payments …

- The Government stated in December 2024 that compensation payments are exempt from income tax, capital gains tax, and inheritance tax, and will be disregarded …

IR2-14 Accepted Urgent

Infected Blood Inquiry (2023)

Arms Length Body Administration

I recommend that an Arms Length Body (ALB) should be set up to administer the compensation scheme, with guaranteed independence of judgement, chaired by a judge of High Court or …

- The Victims and Prisoners Act 2024 Part 3 established the Infected Blood Compensation Authority (IBCA) as a body corporate with guaranteed independence (Victims and …

IR2-15 Accepted

Infected Blood Inquiry (2023)

Support Services for Applicants

I recommend that the scheme should include provision of the following support services to be provided without charge to the applicant: a) an advice and advocacy service, supplemented where necessary …

- The Government stated in December 2024 that it acknowledges the psychological harm caused and is committed to providing support services, including access to independent …

IR2-16 Accepted

Infected Blood Inquiry (2023)

Central Delivery with Devolved Support

I recommend that the compensation scheme should be delivered by one central body, appropriately resourced and staffed. Current support schemes should however continue to be provided as at present by …

- The Victims and Prisoners Act 2024 Part 3 established IBCA as the single central body to deliver the Infected Blood Compensation Scheme (Victims and …

IR2-17 Accepted Urgent

Infected Blood Inquiry (2023)

Bespoke Psychological Service

I recommend that without delay steps be taken to provide a bespoke psychological service in England.

- The Government stated in December 2024 that it acknowledges the psychological harm caused and is committed to providing bespoke psychological support, referencing the Infected …

IR2-18 Accepted Urgent

Infected Blood Inquiry (2023)

Immediate Establishment of Scheme

I recommend that a compensation scheme should be set up now and it should begin work this year.

- The Victims and Prisoners Act 2024 received Royal Assent on 24 May 2024, establishing the legal framework for the compensation scheme (Victims and Prisoners …

1 Accepted in Part

Brook House Inquiry (2023)

Monitor Brook House contract performance robustly

The Home Office must actively and robustly monitor the performance of the Brook House contract, including satisfying itself that any self-reported information is accurate. This may include engagement with monitoring …

- In March 2024, the Home Office stated that it had introduced new contracts requiring internal audit programmes and self-reporting by service providers, with two …

2 Accepted in Part

Brook House Inquiry (2023)

Require IRC contracts to uphold Rule 3 humane detention principles

The Home Office must ensure that each contract for the management of an immigration removal centre must expressly require compliance with the overriding purpose of Rule 3, which is to …

- In March 2024, the Home Office stated that new contracts mandate adherence to Detention Services Orders including the Detention Centre Rules 2001 and that …

3 Accepted in Part

Brook House Inquiry (2023)

Limit cell occupancy to maximum two people

The Home Office must ensure that a maximum of two detained people are accommodated in each cell at Brook House.

- In March 2024, the Home Office stated that all rooms across the removal estate meet standards under Rule 15(1) of the Detention Centre Rules …