Infected Blood Inquiry: recommendations for recognition, healthcare and patient safety

During the 1970s and 1980s, thousands of UK patients contracted HIV, hepatitis viruses, or both, from contaminated blood or blood products. The Infected Blood Inquiry, which investigated the use of contaminated blood products, made several recommendations focused on improving safety and patient care in its final report. This briefing examines these recommendations.

The inquiry’s primary recommendation was that a compensation scheme for those “infected and affected” should be established immediately.

The Infected Blood Inquiry

The Infected Blood Inquiry examined the circumstances in which NHS patients were given infected blood and blood products and the impact of these infections. It also scrutinised the response of the government, health services and professionals, and aimed to identify the organisations and individuals responsible.

The final report of the inquiry was published on 20 May 2024.

Recognition and ongoing care

The inquiry report included recommendations to ensure that the harm caused by infected blood is appropriately recognised and remembered. These include creating a national memorial and providing funding for the infected blood community to maintain their network via regular meetings or events.

Other recommendations focus on the ongoing care and regular monitoring of those who contracted hepatitis C from infected blood or blood products. The report asks health service commissioners to consider how their services meet the needs of these patients. It also recommends that patients are routinely asked about their history of blood transfusions to help identify anyone who has been infected but not yet diagnosed.

Patient safety and voice

The inquiry report says that patient safety must be the “paramount consideration” and a guiding principle for health services and the government. It therefore makes several recommendations that aim to improve patient safety in the NHS. They include specific proposals to improve the safety of blood transfusions and the care of patients with haemophilia (a condition that prevents the blood clotting properly).

Wider recommendations to improve patient safety include:

• A review of the existing statutory duty of candour in England, Wales and Scotland, which requires NHS organisations to be open and transparent about mistakes and harm in patient care, and the introduction of a statutory duty in Northern Ireland.
• Extending the duty of candour to cover individuals in leadership positions in NHS organisations, and making these leaders personally accountable for responding to concerns about patient safety.
• Reviewing and simplifying health care regulation in the UK and considering the introduction of “safety management systems”, following the example of other industries, such as aviation and defence.
• Auditing and progressing work to digitise patient records to ensure that they are complete and accessible to patients.

The report also recommends strengthening the voice of patients by including measures of patient satisfaction in the evaluation of health services, funding charities that represent and support patients affected by infected blood or blood disorders, and raising awareness of the Yellow Card system for reporting side effects and safety concerns about medicines (including blood and blood products).

Response to the inquiry report

Following the publication of the report, the then Prime Minister, Rishi Sunak, committed to studying the report’s recommendations in detail and providing a full response. In July 2024, the Labour government said it was considering the report’s recommendations and would update Parliament on its response before the end of 2024. The devolved executives in Wales, Scotland and Northern Ireland and NHS bodies have issued statements making similar commitments.