Public Inquiry

Infected Blood Inquiry

Status: Completed Chair: Sir Brian Langstaff Established: Sep 2018 Report: May 2024 Commissioned by: Cabinet Office

Examining how thousands of NHS patients were infected with HIV and Hepatitis C through contaminated blood products in the 1970s and 1980s. Found the scandal could largely have been avoided and victims were failed by the NHS, government, and blood …

Response breakdown

103 recommendations total

72%

27%

74 (72%) — Accepted

28 (27%) — Accepted in Part

1 (1%) — Under Review

Reports & milestones

Reports

09 Jul 2025 26 tracked recs Additional Report on Compensation · Tracked recommendations · PDF

20 May 2024 58 tracked recs Infected Blood Inquiry Final Report · Tracked recommendations · PDF

29 Jul 2022 1 tracked rec First Interim Report · Tracked recommendations · PDF

05 Apr 2023 18 tracked recs Second Interim Report · Tracked recommendations · PDF

Timeline

11 Jul 2017 Inquiry Announced Prime Minister Theresa May announced a public inquiry. · Source

11 Jul 2017 Chair Appointed Sir Brian Langstaff appointed as Chair.

25 Jul 2018 Terms of Referenc… Terms of Reference published. · Source

30 Apr 2019 Hearings Begin Public hearings commenced.

19 Jul 2022 First Interim Rep… Interim report on compensation framework. · Source

05 Apr 2023 Second Interim Re… Second interim report with further compensation recommendations.

20 May 2024 Final Report Publ… Final report published finding decades of cover-up. · Source

21 May 2024 Government Apology Prime Minister issued full apology in Parliament. · Source

Recommendations

103 shown

Code	Recommendation	Addressed to	Response
AC-1a	Open Registration The scheme be opened to registration to everyone who may be eligible.	IBCA	Accepted	View →
AC-1b	Registration and Application Forms There be forms (devised by IBCA) for people to register and apply for a core award and the supplementary awards with/without the …	IBCA	Accepted	View →
AC-1c	Legal Support Signposting IBCA include a prominent reference to the availability of legal support paid by IBCA on all registration and application forms and in …	IBCA	Accepted	View →
AC-1d	Three-Cohort Prioritisation When IBCA opens up the service beyond people infected and registered with the support schemes, IBCA: (i) update the sequencing to three …	IBCA	Accepted	View →
AC-1e	Oral Representations at Review IBCA consider making provision, either generally or in specific cases, for oral representations to be made where a decision is reviewed internally, …	IBCA	Accepted	View →
AC-1f	Written Reasons for Decisions Written reasons for the original decision must be provided so that the review process can operate fairly.	IBCA	Accepted	View →
AC-2a	Publish Guidance and Board Minutes IBCA should publish: guidance, advice or instructions to claim managers; work undertaken by IBCA with the Cabinet Office's policy team to ensure …	IBCA	Accepted	View →
AC-2b	Share Clinical Assessor Advice In respect of any case in which the advice of a clinical assessor has been given, in relation to the person concerned …	IBCA	Accepted	View →
AC-2c	Community Advisory Body A formal role be given within IBCA for an advisory body consisting of people infected and affected, covering a range of experience …	IBCA	Accepted	View →
AC-2d	Structured Response to Community Input To build confidence that IBCA is actively listening to people infected and affected, IBCA adopt more of a structured response to contributions …	IBCA	Accepted	View →
IBI-1	Compensation Scheme My principal recommendation remains that a compensation scheme should be set up now	UK Government	Accepted	View →
IBI-2a	UK and Devolved Memorials A permanent memorial be established in the UK and consideration be given to memorials in each of Northern Ireland, Wales and Scotland. …	UK Government	Accepted	View →
IBI-2b	Treloar's School Memorial A memorial be established at public expense, dedicated specifically to the children infected at Treloar’s school. The memorial should be such as …	UK Government	Accepted	View →
IBI-2c	Community Support Events There should be at least three events, approximately six months apart, drawing together those infected and affected, the nature and timing of …	UK Government	Accepted	View →
IBI-3a	Medical Education - Curriculum The General Medical Council, and NHS Education for Scotland, Health Education and Improvement Wales, Northern Ireland Medical and Dental Training Agency and …	GMC UK Government	Accepted	View →
IBI-3b	Medical Education - Training Materials They should look favourably upon putting together a package of training materials, with excerpts from oral and written testimony, to underpin what …	GMC UK Government	Accepted	View →
IBI-3c	Inquiry Website Preservation The Inquiry website is maintained online	UK Government	Accepted	View →
IBI-4a(i)	Duty of Candour - Northern Ireland Duty of candour: A statutory duty of candour in healthcare should be introduced in Northern Ireland.	Northern Ireland Executive	Accepted	View →
IBI-4a(ii)	Duty of Candour - Scotland and Wales Review Duty of candour: The operation of the duties of candour in healthcare in Scotland and in Wales should be reviewed, as it …	UK Government Scottish Government	Accepted	View →
IBI-4a(iii)	Duty of Candour - England Review Duty of candour: The review of the duty of candour currently under way in England should be completed as soon as practicable.	UK Government	Accepted	View →
IBI-4a(iv)	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 …	UK Government	Accepted in Part	View →
IBI-4a(v)	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 …	UK Government	Accepted in Part	View →
IBI-4b	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 …	UK Government	Accepted in Part	View →
IBI-4c(i)	Simplify External Regulation Regulation: That external regulation of safety in healthcare be simplified. As a first step towards this, there should be a UK wide …	UK Government	Accepted	View →
IBI-4c(ii)	Safety Management Systems Coordination Regulation: That the national healthcare administrations in England, Northern Ireland, Scotland and Wales explore, and if appropriate, support the development and implementation …	UK Government	Accepted	View →
IBI-4d	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 …	UK Government	Accepted	View →
IBI-4e	Cross-Administration Patient Safety Coordination Coordination of patient records with devolved governments: Consideration should be given by the national healthcare administrations in England, Scotland, Wales and Northern …	UK Government	Accepted	View →
IBI-5a	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 …	UK Government	Accepted in Part	View →
IBI-5b	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, …	UK Government	Accepted in Part	View →
IBI-5c	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 …	UK Government	Accepted in Part	View →
IBI-6a(i)	Hepatologist Oversight and Fibroscan Access All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have been …	UK Government	Accepted	View →
IBI-6a(ii)	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 …	UK Government	Accepted in Part	View →
IBI-6a(iii)	Uncertainty About Fibrosis All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Where there is any …	UK Government	Accepted	View →
IBI-6a(iv)	Fibroscan for Liver Imaging All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Fibroscan technology should be …	UK Government	Accepted	View →
IBI-6a(v)	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 …	UK Government	Accepted in Part	View →
IBI-6a(vi)	Commissioning Hepatology Services All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those bodies responsible for …	UK Government	Accepted	View →
IBI-7a(i)	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 …	UK Government	Accepted in Part	View →
IBI-7a(ii)	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 …	UK Government	Accepted	View →
IBI-7a(iii)	Transfusion Performance Benchmarking Consideration be given to standardising and benchmarking transfusion performance between hospitals in order to deliver better patient blood management	UK Government	Accepted	View →
IBI-7b	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 …	UK Government	Accepted	View →
IBI-7c	Transfusion Laboratory Staffing Transfusion laboratories: Transfusion laboratories should be staffed (and resourced) adequately to meet the requirements of their functions.	UK Government	Accepted in Part	View →
IBI-7d	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 …	UK Government	Accepted in Part	View →
IBI-7e	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 …	UK Government	Accepted in Part	View →
IBI-7f(i)	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 …	UK Government	Accepted	View →
IBI-7f(ii)	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 …	UK Government	Accepted	View →
IBI-7f(iii)	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 …	UK Government	Accepted in Part	View →
IBI-8a	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 …	UK Government NHS England	Accepted	View →
IBI-8b	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.	UK Government NHS England	Accepted	View →
IBI-9a	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 …	UK Government	Accepted	View →
IBI-9b	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 …	UK Government	Accepted	View →
IBI-9c	Five-Year Peer Review Cycle A peer review of each centre should take place not less than once every five years.	UK Government	Accepted	View →
IBI-9d	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 …	UK Government	Accepted	View →
IBI-9e	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 …	UK Government	Accepted	View →
IBI-9f	National Haemophilia Database Support That the National Haemophilia Database, run by the UKHCDO, merits the support of additional central funding.	UK Government	Accepted	View →
IBI-10a(i)	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 …	UK Government	Accepted	View →
IBI-10a(ii)	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 …	UK Government	Accepted	View →
IBI-10a(iii)	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 …	UK Government	Accepted	View →
IBI-10a(iv)	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 …	UK Government	Accepted in Part	View →
IBI-10a(v)	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 …	UK Government	Accepted	View →
IBI-11a	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 …	UK Government	Accepted in Part	View →
IBI-11b	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 …	UK Government	Accepted in Part	View →
IBI-11c	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 …	UK Government	Accepted in Part	View →
IBI-11d	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 …	UK Government	Accepted in Part	View →
IBI-12a	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 …	UK Government	Accepted	View →
IBI-12b	Parliamentary Progress Report During that period, and before the end of this year – the Government should report back to Parliament as to the progress …	UK Government	Accepted	View →
IBI-12c	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.	UK Government	Accepted	View →
IBI-12d	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 …	UK Government	Accepted in Part	View →
IBI-12e	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 …	UK Government	Accepted in Part	View →
IBI-A-2e	Transparency of Scheme Design The Government and IBCA establish a mechanism by which individuals or organisations may raise concerns which arise about any aspect of the …	UK Government	Accepted	View →
IBI-A-3a	HIV Eligibility Start Date An amendment to the Regulations be made as soon as possible to remove the reference to 1 January 1982 from Regulation 3.	UK Government	Accepted	View →
IBI-A-4a	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 …	UK Government	Accepted in Part	View →
IBI-A-4b	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 …	UK Government	Accepted in Part	View →
IBI-A-4c	Effective Treatment - Earnings Floor For the calculation of Financial Loss awards for Hepatitis B, people born after 1953 should be treated like those born in or …	UK Government	Accepted	View →
IBI-A-4d	Deeming of Severity Bands Where the level of severity of a person's infection at Level 3 or more has been established to IBCA's satisfaction in relation …	UK Government	Accepted	View →
IBI-A-4e	Evidence of Diagnosis Date Regulation 14(2)(c) be amended to remove the requirement for evidence of the date of diagnosis of Hepatitis B or C. An appropriate …	UK Government	Accepted	View →
IBI-A-5a	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 …	UK Government	Accepted in Part	View →
IBI-A-6a	Financial Loss and Care "x" be removed from the equation set out in Regulation 7.	UK Government	Accepted in Part	View →
IBI-A-6b	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 …	UK Government	Accepted in Part	View →
IBI-A-7a	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 …	UK Government	Accepted in Part	View →
IBI-A-7b	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 …	UK Government	Accepted in Part	View →
IBI-A-7c	Unethical Research Award Amount Review The Minister consider whether the £10,000 (£15,000 for Treloar's pupils) should in justice be increased and further decides what sum he considers …	UK Government	Under Consideration	View →
IBI-A-8a	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 …	UK Government	Accepted in Part	View →
IBI-A-8b	Affected Estates The Regulations be amended such that where someone who would be an eligible affected person dies between 21 May 2024 and 31 …	UK Government	Accepted	View →
IBI-A-9a	Bereaved Partner Support Scheme The IBSS cut-off date of 31 March 2025 be reviewed, that the scheme should as soon as possible reinstate support payments to …	UK Government	Accepted	View →
IR1-1	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 …	UK Government	Accepted	View →
IR2-1	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 …	UK Government	Accepted	View →
IR2-2	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 …	UK Government	Accepted	View →
IR2-3	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 …	UK Government	Accepted	View →
IR2-4	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 …	UK Government	Accepted	View →
IR2-5	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 …	UK Government	Accepted	View →
IR2-6	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 …	UK Government	Accepted	View →
IR2-7	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 …	UK Government	Accepted	View →
IR2-8	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 …	UK Government	Accepted	View →
IR2-9	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 …	UK Government	Accepted	View →
IR2-10	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, …	UK Government	Accepted	View →
IR2-11	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 …	UK Government	Accepted	View →
IR2-12	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 …	UK Government	Accepted	View →
IR2-13	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 …	UK Government	Accepted	View →
IR2-14	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, …	UK Government	Accepted	View →
IR2-15	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) …	UK Government	Accepted	View →
IR2-16	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 …	UK Government	Accepted	View →
IR2-17	Bespoke Psychological Service I recommend that without delay steps be taken to provide a bespoke psychological service in England.	UK Government	Accepted	View →
IR2-18	Immediate Establishment of Scheme I recommend that a compensation scheme should be set up now and it should begin work this year.	UK Government	Accepted	View →

Parliamentary activity

386 mentions since Sep 2017

52 debates 284 questions 45 statements

15 Jun 2026 Early Day Motion Infected Blood Inquiry compensation
Lisa Smart (Liberal Democrat)

19 May 2026 Written Question Infected Blood Inquiry: Costs
Mike Wood (Conservative)

13 May 2026 Early Day Motion Redress for people impacted by surgical mesh, sodium valproate and Primodos
Sarah Green (Liberal Democrat)

14 Apr 2026 Written Ministerial Statement Update on the Infected Blood Compensation Scheme
Baroness Anderson of Stoke-on-Trent (Labour)

14 Apr 2026 Written Ministerial Statement Update on the Infected Blood Compensation Scheme
Nick Thomas-Symonds (Labour)

View all 386 mentions →

Costs

Total: £146,162,778

Period	Total	Inquiry legal	CP legal	Source
Mar 2025 (cum.)	£146,162,778	£67,290,993	£27,242,761	link
Mar 2025	£5,511,059	£1,514,906	£603,277	link
Mar 2024	£10,301,344	£5,354,237	£937,131	link
Mar 2023	£28,254,992	£11,694,492	£7,154,110	link
Mar 2022	£32,522,939	£15,491,533	£5,778,813	link
Mar 2021	£34,270,948	£20,797,365	£4,505,612	link
Mar 2020	£25,992,907	£9,959,119	£5,742,876	link
Mar 2019	£9,308,693	£2,479,341	£2,520,943	link