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

58 shown (filtered)

Code	Recommendation	Addressed to	Response
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 →

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