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).

Government response to the inquiry report

The government published an initial response to the infected blood inquiry report in December 2024, followed by a full response on 14 May 2025. These responses say that the UK Government and the devolved administrations in Scotland, Wales and Northern Ireland “have accepted the Inquiry’s recommendations in full or accept them in principle”.

The inquiry’s recommendations about compensation, memorials and incorporating lessons from infected blood into healthcare professionals’ training were all accepted in full by the UK Government and the devolved administrations. In other areas, some recommendations or parts of recommendations are accepted in full, and others in principle, and the response varies across the UK.

When a recommendation has been accepted in principle, the government says that it accepts the inquiry’s rationale for change, but that further work must be conducted to “fully understand the implications of implementing complex recommendations”, including costs and different ways of achieving recommended outcomes.

For example, the inquiry’s recommendations about reviewing the statutory duty of candour in healthcare in England, Scotland and Wales were accepted in full. Its recommendations about extending this duty to NHS leaders and civil servants were accepted in principle. The government said it was considering how these proposals would interact with other initiatives, including a consultation on the regulation of NHS managers and the proposed ‘Hillsborough Law’.