Infected Blood Inquiry

My principal recommendation remains that a compensation scheme should be set up now

The Inquiry recommended the immediate establishment of a compensation scheme. In July 2026, Mabon ap Gwynfor, Cabinet Minister for Health and Care in the Welsh Government, stated that progress had been made establishing the scheme and beginning payments, but noted issues raised by beneficiaries regarding the pace of claims processing and payments (Mabon ap Gwynfor, Jul 2026). Nick Thomas-Symonds, Minister for the Cabinet Office and Paymaster General, reported in April 2026 that over 3,200 compensation offers had been made, with over £2 billion paid in compensation and £1.4 billion in interim payments (Nick Thomas-Symonds, Apr 2026). The National Audit Office found in April 2026 that scheme funding had reached £12.8 billion, following regulations in August 2024 that established the Infected Blood Compensation Authority (IBCA) to administer payments (Gareth Davies, Apr 2026; Gareth Davies, Apr 2026).

A permanent memorial be established in the UK and consideration be given to memorials in each of Northern Ireland, Wales and Scotland. The nature of the memorial(s), their design and location should be determined by a memorial committee consisting of people infected and affected and representatives of the governments. It should be funded by the UK government.

The Inquiry recommended establishing permanent United Kingdom (UK) and devolved memorials. In August 2026, the Infected Blood Memorial Committee stated that memorials will be established in Scotland, Wales, Northern Ireland and England, agreeing that the overarching UK memorial should be in England with a working hypothesis of London (Infected Blood Memorial Committee, Aug 2026). The Committee noted that a decision is still needed on where in England the UK memorial should be (Infected Blood Memorial Committee, Aug 2026). In July 2025, Nick Thomas-Symonds, Paymaster General and Minister for the Cabinet Office, announced the appointment of Clive Smith as chair of the committee (Nick Thomas-Symonds, Jul 2025). In May 2025, the UK Government stated that it was following the recommendation to form a steering committee and that memorials would be provided primarily at public expense (Cabinet Office response, May 2025).

A memorial be established at public expense, dedicated specifically to the children infected at Treloar’s school. The memorial should be such as is agreed with those who were pupils at Treloar’s.

The Inquiry recommended establishing a memorial for children infected at Treloar's School. In December 2025, the Infected Blood Memorial Committee reported that local council planning permission had been granted for a finalised bronze sculpture design at the school, with working with an artist and foundry to build it remaining outstanding, though agreement with former pupils was not mentioned (Infected Blood Memorial Committee, Dec 2025). Earlier, in July 2025, Nick Thomas-Symonds, Paymaster General and Minister for the Cabinet Office, announced to Parliament that Clive Smith had been appointed chair of the memorial committee (Nick Thomas-Symonds, Jul 2025). In May 2025, the UK Government accepted the recommendation, confirming that a dedicated sub-committee would consider the memorial and that it would be funded primarily at public expense (Cabinet Office response, May 2025).

There should be at least three events, approximately six months apart, drawing together those infected and affected, the nature and timing of which should be determined by a working party as described above, facilitated by some central funding.

The Inquiry recommended at least three support events for those infected and affected. In July 2026, the Infected Blood Memorial Committee reported spending £169,525.88 on commemorative events, noting that the time and date of a third event remained to be determined (Infected Blood Memorial Committee, Jul 2026). In July 2025, Nick Thomas-Symonds, Paymaster General and Minister for the Cabinet Office, announced that Clive Smith had been appointed chair of the committee (Nick Thomas-Symonds, Jul 2025). In May 2025, the UK Government stated that a sub-committee would be established to organise biannual networking and support events (Cabinet Office response, May 2025).

The General Medical Council, and NHS Education for Scotland, Health Education and Improvement Wales, Northern Ireland Medical and Dental Training Agency and NHS England, should take steps to ensure that those “lessons to be learned” which relate to clinical practice should be incorporated in every doctor’s training.

An action log owned by Emma Watson of NHS Education for Scotland, as minuted by the Scottish Government in March 2026, recorded that funding had been agreed with the body to take forward recommendation 3 (The action log, Mar 2026). In November 2025, she reported that a group led by NHS England to address the recommendations had been disbanded due to funding constraints (Professor Emma Watson, Nov 2025). Earlier, the UK Government stated in May 2025 that the General Medical Council was surveying educational institutions and working with four-nation leaders to identify training gaps (Cabinet Office response, May 2025).

They should look favourably upon putting together a package of training materials, with excerpts from oral and written testimony, to underpin what can happen in healthcare, and must be avoided in future.

An action log for Professor Emma Watson of NHS Education for Scotland, minuted by the Scottish Government in March 2026, recorded that funding had been agreed with it to take forward the recommendation (The action log, Mar 2026). In November 2025, she reported that an NHS England-led group addressing the recommendation had been disbanded due to funding constraints (Professor Emma Watson, Nov 2025). In May 2025, the UK Government stated that the General Medical Council accepted the recommendation and was reviewing training arrangements while four-nation work identified gaps to implement educational resources (Cabinet Office response, May 2025).

The Inquiry website is maintained online

In May 2025, the UK Government accepted the recommendation and stated that it was taking forward work to ensure the website is maintained with full functionality after the Inquiry closes (Cabinet Office response, May 2025). It noted that a standard transfer to The National Archives leads to lost search engine capacity, but work was underway to keep all uncovered information easily publicly available (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).

Duty of candour: A statutory duty of candour in healthcare should be introduced in Northern Ireland.

The Inquiry recommended introducing a statutory duty of candour in healthcare across Northern Ireland. In September 2025, Mike Nesbitt, Minister of Health, stated in a written ministerial statement to the Northern Ireland Assembly that officials had been tasked with developing a bill for an organisational duty of candour during the current mandate (Mike Nesbitt, Sep 2025). Previously, in May 2025, the Northern Ireland Executive stated that it would advance an organisational duty first while considering an individual duty later, taking into account consultation findings and wider UK legislative work (Northern Ireland Executive response, May 2025).

Duty of candour: The operation of the duties of candour in healthcare in Scotland and in Wales should be reviewed, as it is being in England, to assess how effective its operation has been in practice. Since the duty was introduced in 2023 in Wales, the review there need not be immediate, but should be no later than the end of 2026.

The Inquiry recommended reviewing how healthcare duties of candour operate in Scotland and Wales. For Scotland, Lynne Nicol of the Scottish Government stated at a March 2026 meeting, in minutes published in May 2026, that its review was completed in December 2025 and a resulting programme of work is being developed for the new parliamentary term (Lynne Nicol, Mar 2026). For Wales, the Welsh Government stated in May 2025 that the duty introduced there in 2023 will be evaluated, with the recommendation integrated into a specification out to tender for an evaluation research programme (Welsh Government response, May 2025).

Duty of candour: The review of the duty of candour currently under way in England should be completed as soon as practicable.

In May 2025, the UK Government accepted the recommendation, stating that although findings from a November 2024 call for evidence showed the statutory duty was "underwhelming in totality", completing the review remained outstanding while it prepared a response to a related consultation on manager regulation to inform the final report (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).

Regulation: That external regulation of safety in healthcare be simplified. As a first step towards this, there should be a UK wide review by the four health departments of the systems of external regulation, with the aim of addressing all the points made earlier in this Report and in other reports since 2000.

In May 2025, the UK Government stated that the Secretary of State for Health and Social Care had asked Dr Penny Dash to review patient safety across six core regulatory bodies to determine whether a different approach or delivery model could achieve greater value, adding that the review would be published shortly to inform its ten-year health plan and an NHS Quality Strategy (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).

Regulation: That the national healthcare administrations in England, Northern Ireland, Scotland and Wales explore, and if appropriate, support the development and implementation of safety management systems (“SMS”s) through SMS coordination groups (as recommended by the HSSIB), and do so as a matter of priority.

In May 2025, the UK Government accepted the recommendation, stating that NHS England had established a coordination group in 2023 to explore adapting safety management systems for healthcare (Cabinet Office response, May 2025). It added in that response that the group's work remained ongoing without reaching specific conclusions and was likely to report later in 2025 (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).

Coordination of patient records with devolved governments: Consideration should be given by the national healthcare administrations in England, Scotland, Wales and Northern Ireland, to further coordination of their approaches particularly to ensure that patterns of harm, or trends, are identified and any response which for the sake of patient safety would be better coordinated than left to each individual administration can collaboratively be agreed and implemented.

In May 2025, the UK Government reported that the recommendation was "accepted in full by the UK Government, the Welsh Government, the Scottish Government and the Northern Ireland Executive", pointing to NHS England's Learn From Patient Safety Events service as a model for recording incidents and issuing safety alerts (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).

All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have been diagnosed with cirrhosis at any point should receive lifetime monitoring by way of six-monthly fibroscans and annual clinical review, either nurse-led, consultant-led or, where appropriate, by a GP with a specialist interest in hepatitis

The Inquiry recommended lifetime six-monthly fibroscans and annual reviews for hepatitis cirrhosis patients. In May 2025, the UK Government stated that it accepted the recommendation, balancing implementation against clinical guidelines and equitable access (Cabinet Office response, May 2025). It described plans for consultant hepatologist oversight, a referral framework for fibroscans, and a new National Health Service (NHS) cirrhosis surveillance registry, though six-monthly fibroscans and annual reviews are not mentioned in the sources (Cabinet Office response, May 2025).

All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Where there is any uncertainty about whether a patient has fibrosis they should receive the same care

The Inquiry recommended that hepatitis patients with uncertainty about fibrosis receive the same care. In May 2025, the UK Government accepted the recommendation, stating that implementation would be balanced against clinical guidelines and the principle that care should not depend on how infection was acquired (Cabinet Office response, May 2025). It noted that National Health Service (NHS) England is developing a framework to identify bleeding disorder patients lacking fibrosis staging to refer them for scans, alongside introducing a cirrhosis surveillance registry (Cabinet Office response, May 2025).

All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Fibroscan technology should be used for liver imaging, rather than alternatives

The Inquiry recommended that patients infected with hepatitis through blood receive Fibroscan liver imaging. In May 2025, the UK Government stated that it accepted the recommendation, though implementation would be balanced against clinical guidelines and equitable access across the National Health Service (NHS) (Cabinet Office response, May 2025). It noted that NHS England was developing a framework to enable referrals for Fibroscan testing for patients with bleeding disorders, while a cirrhosis surveillance registry remained to be introduced (Cabinet Office response, May 2025).

All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those bodies responsible for commissioning hepatology services in each of the home nations should publish the steps they have taken to satisfy themselves that the services they are commissioning meet the particular needs of the group of people harmed by NHS treatment

The Inquiry asked home nation hepatology commissioners to publish how services meet harmed patients' needs. In May 2025, the UK Government accepted the recommendation, stating it would balance implementation against equitable access, and reported that National Health Service (NHS) England had audited care pathways (Cabinet Office response, May 2025). It described developing a framework to identify exposed patients with bleeding disorders and introducing a cirrhosis surveillance registry, but publishing steps taken by commissioners across each home nation was not mentioned (Cabinet Office response, May 2025).

Consideration be given to standardising and benchmarking transfusion performance between hospitals in order to deliver better patient blood management

In November 2025, Dr Lorna McLintock of the Scottish National Blood Transfusion Service reported that all Scottish health boards had confirmed using its clinical transfusion dashboard and that a UK-wide benchmarking group had been established (Dr Lorna McLintock, Nov 2025). Earlier, in May 2025, the UK Government accepted the recommendation, stating that it had initiated a review of benchmarking practices, requested updated guidance from the National Institute for Health and Care Excellence, and was working with the Care Quality Commission, though developing new benchmarking categories and funding to expand the model health dashboard were still required (Cabinet Office response, May 2025).

When doctors become aware that a patient has had a blood transfusion prior to 1996, that patient should be offered a blood test for Hepatitis C.

The Inquiry recommended offering Hepatitis C tests to patients who had pre-1996 blood transfusions. In May 2025, the UK Government accepted the recommendation, stating that changes to the General Practice (GP) Online Registration service were ready to launch at the end of that month alongside supporting NHS England guidance (Cabinet Office response, May 2025). In the same month, the Scottish Government and the Welsh Government both reported issuing clinical circulars asking healthcare staff to question patients about previous transfusions and offer testing (Scottish Government response, May 2025; Welsh Government response, May 2025). The Northern Ireland Executive reported in May 2025 that circular guidance had been issued, while engagement remained ongoing to determine the registration approach for primary care (Northern Ireland Executive response, May 2025). The record holds nothing dated later than the response of May 2025 (Northern Ireland Executive response, May 2025).

As a matter of routine, new patients registering at a practice should be asked if they have had such a transfusion.

The Inquiry recommended routinely asking newly registered patients whether they have had a blood transfusion. In May 2025, the UK Government stated that it accepted the recommendation, noting that changes to the General Practitioner (GP) Online Registration service had been agreed for national rollout at the end of that month alongside supporting NHS England guidance (Cabinet Office response, May 2025). The Scottish Government and the Welsh Government reported in May 2025 that they had issued circulars directing primary care staff to ask new patients about previous blood transfusions (Scottish Government response, May 2025; Welsh Government response, May 2025). The Northern Ireland Executive stated in May 2025 that engagement remained ongoing with primary care policy leads to determine the best approach for general practice registration (Northern Ireland Executive response, May 2025). The record holds nothing dated later than the response of May 2025 (Northern Ireland Executive response, May 2025).

That peer review of haemophilia care should continue to occur as presently practised, with any necessary support being provided by NHS Trusts and Health Boards;

The Inquiry recommended that peer review of haemophilia care continue with health service support. In April 2026, Parliamentary Under-Secretary of State at the Department of Health and Social Care Dr Zubir Ahmed stated that a five-year peer review cycle continues and a final report is expected imminently, alongside planned letters seeking commitment from local boards and an updated service specification undergoing final approvals following public consultation (Dr Zubir Ahmed, Apr 2026). In May 2025, the UK Government stated that the revised service specification was intended to proceed to public consultation that summer (Cabinet Office response, May 2025).

That the following charities receive funding specifically for patient advocacy: the UK Haemophilia Society; the Hepatitis C Trust; Haemophilia Scotland; the Scottish Infected Blood Forum; Haemophilia Wales; Haemophilia Northern Ireland; and the UK Thalassaemia Society.

In July 2025, Paymaster General and Minister for the Cabinet Office Nick Thomas-Symonds stated that the Department for Health and Social Care was re-examining advocacy funding for that year and exploring options for the future after charities raised issues regarding their allocations (Nick Thomas-Symonds, Jul 2025). The UK Government had previously announced in May 2025 that £500,000 would be provided across named charities, with meetings taking place to determine individual grant awards (Cabinet Office response, May 2025).

That favourable consideration be given to other charities and organisations supporting people infected and affected that were granted core participant status (as listed on the Inquiry website) to continue to provide support for at least the next 18 months. Further support should be reviewed at that stage with a view to it continuing as appropriate.

The Inquiry recommended continued support for core participant organisations helping infected and affected individuals. In May 2025, the UK Government stated that "consideration is being given as to how to best support organisations and charities" covered by this recommendation (Cabinet Office response, May 2025). It affirmed that it remained committed to supporting these organisations as appropriate (Cabinet Office response, May 2025). The recommendation's provisions for at least 18 months of support and a subsequent review were not mentioned in the response (Cabinet Office response, May 2025). The record holds nothing dated later than the response of May 2025 (Cabinet Office response, May 2025).

Steps be taken to give greater prominence to the online Yellow Card system to those receiving drugs or biological products, or who are being transfused with blood components.

In May 2025, the UK Government accepted the recommendation, stating that the Medicines and Healthcare Regulatory Agency had begun regional awareness workshops and that Yellow Card platform changes were undergoing user acceptance testing for delivery by September 2025 (Cabinet Office response, May 2025). It noted in May 2025 that a scoping meeting for final delivery of the changes was to be arranged alongside further promotional activities (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).

Within the next 12 months, the Government should consider and either commit to implementing the recommendations which I make, 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. This timetable should not interfere with earlier consideration and response to the Recommendations of the Second Interim Report of the Inquiry.

The UK Government stated in its May 2025 response, presented to Parliament by the Minister for the Cabinet Office, that its comprehensive document on the implementation of the recommendations by all of the UK's administrations replaced its December 2024 update and fulfilled the obligations set out in recommendation 12a (Cabinet Office response, May 2025; Cabinet Office, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).

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 UK Government stated in its formal response of May 2025, presented to Parliament by the Minister for the Cabinet Office, that its December 2024 parliamentary update fulfilled the obligations set out in this recommendation, and it recorded the recommendation's delivery status as completed (Cabinet Office response, May 2025; Cabinet Office, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025; Cabinet Office, May 2025).

This timetable should not interfere with earlier consideration and response to the Recommendations of the Second Interim Report of the Inquiry.

In May 2025, the UK Government accepted the recommendation, stating that detail set out under recommendation 1 met its formal obligation to respond to the Second Interim Report, alongside its August 2024 summary of the Infected Blood Compensation Scheme (Cabinet Office response, May 2025). It noted that its position on compensation was also informed by parliamentary debate and community engagement led by Sir Robert Francis (Cabinet Office response, May 2025). The record holds no update since the UK Government's response of May 2025 (Cabinet Office response, May 2025).