Summary of Blood Inquiry report

The Infected Blood Inquiry published its report on Monday 20 May 2024 after five years of intense scrutiny of the many bodies involved over a period of the last fifty years and more. Successive health ministers, civil service heads, former and current Prime Ministers and Chancellors of the Exchequer gave evidence. With some exceptions, including the much-criticised evidence of Kenneth Clarke, to a large extent it seemed to go under the radar,  unnoticed - until this week.

Those of us who work in the healthcare arena are used to the publication of reports into NHS scandals and to repeated findings - from Ian Kennedy’s report into Bristol paediatric surgery (Sir Brian describes this as ‘optimistically entitled Learning from Bristol’; who could forget the tiny cardboard coffins in the street?), through the murder of hundreds of patients by Shipman, Sir Liam Donaldson’s Organisation with a Memory, Mid Staffs, Morecambe Bay, Okenden, Cumberledge and the rest. And it seems that the more things change, the more they stay the same. 

But this report feels different, and there might just be a chance here of a real and important change of cultural shift.

The report is in seven volumes and is some 2,700 pages in length. The Inquiry chair, Sir Brian Langstaff, received hundreds of pages of submissions on the recommendations he might make.  Explaining that ‘There is a danger in Inquiries making too many recommendations; it becomes difficult to see whether action is truly being taken to avoid the errors of the past being repeated’, he acknowledged that his approach may disappoint some and made just twelve recommendations. The small number belies their scope and significance.

Of the twelve recommendations, the first was compensation, referring to his comprehensive interim report, a recommendation which has already been accepted by the Government.

The second is recognising and remembering what happened to people and the importance of fitting memorials. This recommendation bears consideration by healthcare organisations, government and all those who may have cause to issue an apology that will not be received as ‘hollow’ (as I write this there is much response to the apology by Paula Vennells at the start of her evidence to the Post Office Inquiry which is instructive). An apology includes three components: remorse, admission of fault and action; it includes accountability; states what is being apologised for and leads to stated action, which is taken. Very many apologies have been given; some may need to be revisited.  Sir Brian singled out the Scottish Blood Service closing submissions as a good example.

The third recommendation was Learning from the Inquiry including that doctors should be educated in, and understand, the ‘hard and awful’ facts of what happened. Key information from the Inquiry is to remain available, maintained on-line with full functionality so that precious learning is preserved and does not end with the Inquiry.

The important recommendation for the wider NHS is recommendation 4. It is old but new: Preventing future harm to patients; achieving a Safety Culture responds to the failures to put safety first and listen to voices advising a different course. It demands action in three aspects (which are not for the faint-hearted or easily deterred):

• first, changing culture so that safety is embedded as the first principle
• second, a more rational approach to regulation and safety management – a ‘decluttering’ of a system which is ‘fragmented, overlapping, confusing and poorly understood’. Or in Baroness Cumberledge’s words ‘disjointed, siloed, unresponsive and defensive’
• third, ensuring a coherent approach to data – to identify threats and trends and better inform protection.

The Paterson, Cumberledge and Ockenden reports describe ‘a fragmented system with patient safety concerns falling through the gaps and the patient voice being lost.’ No single body is charged with ensuring an effective safety system. Sir Brian notes the findings of the NHS Staff survey – ‘We are not getting Safer’.

Culture will not change unless candour is ensured

The Government has recently signed Archbishop James Jones’s Charter of six undertakings borne out of his report: ‘The Patronising Disposition of Unaccountable Power’. Six words that speak volumes. If you take nothing else from this, take this pledge:

 ‘Place the public interest above our own reputation.’

Bristol found that: ‘The patient must be at the centre of everything the NHS does’. In his report on Mid-Staffordshire, Sir Robert Francis delivered the statutory duty of candour in the NHS. But, Sir Brian notes, ‘there are many leaders who are as yet subject to no individual accountability for candour within their organisation’ – those not subject to medical regulation.

The Broken Trust, Groundhog Day 2, the need for Martha’s Rule; whoever first coined the term ‘patient’ was right.

Freedom to speak up – ‘a human, professional and statutory duty’

Do you insist on the reporting of concerns? If not, please read this section ; and if you can, the rest of this report. Sir Brian says that failure to give a report of concerns proper consideration should be regarded as culpable.

Leadership in the NHS  - Not me Gov……

Anyone who reads this section and thinks it couldn’t apply to them, that it couldn’t happen ‘here’, should think again.

JVT gave evidence. It was well received. He avoided football and transport metaphors and spoke instead of ‘a set of personal values’ and of ‘built in ownership and accountability’.

Cultural change

Sir Brian found that: a culture of defensiveness, lack of openness, failure to be forthcoming, and being dismissive of concerns about patient safety be addressed …. by making leaders accountable for how the culture operates in their part of the system, and for the way in which it involves patients’

And that:

‘ 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 the healthcare being provided, or the way it is being provided, where there reasonably appears to be a risk that a patient might suffer harm, or has done so. Any person in authority to whom such a report is made should be personally accountable for a failure to consider it adequately’.

A Safety Management System – HSSIB and an overall systems approach

Does this mean anything to you? A powerful consensus has been building and in conjunction with PSIRF there is a chance here to drive change for the better.

Record-keeping

Not easy at the best of times. But surely, we can and must do better. To be improved – and audited.

Recommendation 5. ending the defensive culture in the Civil Service and Government

Not at first sight applicable to the NHS, but the chapter on Lines to Take lays out the consequences of civil servants and ministers adopting lines to take without sufficient reflection, ‘which were inaccurate, partial when they should have been qualified, had no proper evidential foundation, ignored findings made by courts which were inconsistent (or flatly contradictory of) the lines adopted, or made unrealistic claims that treatment had been the best it could be.

Groupthink

In relation to Hepatitis C, Ministers took on faith what civil servants said; civil servants took on faith what the files said. No one stood back and reflected. No one asked questions – could this really be right? How could the best treatment available lead to the infection of so many?’

A dogma became a mantra. This compounded the suffering. It was cruel. ‘No one can sensibly dispute that people in public life should observe basic moral principles: they are as applicable to government ministers and officials as they are to clinicians’.

Put blame not on those who raise concerns, but on those who knowing of a matter of concern, do not then raise it, or who ignore concerns raised.

Sir Brian has recommended that those in leadership positions in the health service, who would not otherwise be within the scope of a statutory duty of candour, should be made subject to it, and made accountable for their personal handling of concerns about the safety of healthcare amongst those they lead. Recognition of a corresponding duty of leaders in the Civil Service is also recommended.

Andy Burham, who used his final speech in the House of Commons before standing down from Parliament to call for this Inquiry, was loudly cheered at the publication of this report. Asked that night on Newsnight why he, as Secretary of State for Health, did not question these matters then he explained: ‘They lied to me’.

Sir Brian says – ‘The duty of ministers is to be properly reflective, curious and prepared if need be to be critical of advice’.

What are your sacred cows? What makes you think - why are you asking me this. Everybody knows….. Just as yesterday’s heresies can be today’s truths, yesterday’s truths might just be today’s heresies.

Many of the remaining recommendations are particular to the events being considered.

Recommendation 6- covers the need for monitoring of those with liver damage.

Recommendation 7 -Patient Safety and Blood Transfusions closely follows recommendations suggested by NHS Blood and Transplant in their closing submissions. It addresses the five year plan set out in Transfusion 2024 including Transfusion Laboratory Safety, Information Technology, and Recommendations for further research and development. It takes up the opportunity sought by NHSBT to improve transfusion safely more widely than in relation to TTIs- transfusion-transmitted infections, which are thankfully now a tiny percentage of the complications of transfusion.

The recommendation covers safe staffing and adequate resourcing of hospital laboratories, training in transfusion medicine and in the appropriate use of transfusion and alternatives such as tranexamic acid, which should now be included in all surgical checklists.

It recommends 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 implementation.

Recommendation 8 is finding the undiagnosed – testing anyone who had a transfusion before 1996 and asking patients on registration at a new practice if they have ever had a transfusion.

Recommendation  9 relates specifically to haemophilia care.

Recommendation 10 – ‘Giving patients a voice’.

Clinical audit should include measures of patient satisfaction or concern which are reported to the Board.

Recommendation 11 addresses the response to calls for a public inquiry.

Recommendation 12 : ‘Giving effect to the Recommendations of the Inquiry’.

Within the next 12 months, the Government should consider and either commit to implementing the recommendations made, or give sufficient reason, in sufficient detail for others to understand, why it is not considered appropriate to implement any one or more of them.

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 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.

Summary

Those involved in the Thirwall Inquiry will note the resonance with some of the Terms of Reference:

- whether the trust’s culture, management and governance structures and processes contributed to the failure to protect babies from Lucy Letby;

- The effectiveness of NHS management and governance structures and processes, external scrutiny and professional regulation in keeping babies in hospital safe and well looked after, whether changes are necessary and, if so, what they should be, including how accountability of senior managers should be strengthened and consideration of NHS culture.

Weightmans was privileged to act for NHS Blood and Transplant and the former blood services in their response to the Infected Blood Inquiry. They made our job easy. They supported the Inquiry from the outset and embraced it. They signed up to Archbishop James Jones’s charter; they handed over their archive of 90,000 boxes of documents and gave access to their IT systems; at Sir Brian’s invitation they waived legal professional privilege. Of the over 100,000 documents the Inquiry reviewed, they provided over half, including copies of some thought to be missing or destroyed. They had no position but followed the evidence. Over twenty of their current and former employees (mostly in their eighties and nineties) spent weeks and months reviewing documents and providing evidence. 

NHSBT embraced the Inquiry as an opportunity to learn, to improve and as a force for positive change going forward. They are grateful to Sir Brian for his meticulous work and the recommendations he makes that will contribute to the safety of blood and blood transfusion.