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The transfusion threshold fell over the years, as patients with lymphoma required fewer red cells and platelet transfusions. However, treatment with aggressive chemotherapy still involved transfusion, and patients with myeloma frequently required red cells but rarely platelets.

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In his written evidence to the Inquiry, Professor Goldstone noted that there had been an increasing tendency over the past 30 years to think twice about the administration of any blood product on grounds of risk.

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There were no digital versions of national transfusion guidance initially, and the British Committee for Standards in Haematology guidelines on platelets were rarely read by clinicians.

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In Wales, it was common amongst orthopaedic surgeons at the Morriston Hospital to transfuse two to three units when performing total knee replacements.

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Dr Thomas became a key proponent of the red cell salvage technique, which led to transfusions in total knee replacement surgery decreasing from 82% to 27% and then to 7%.

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A hospital transfusion practitioner at the Morriston Hospital devised a transfusion record chart to aid record keeping and enhancing traceability of transfused components. This was subsequently used across Wales.

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Dr David Bogod told the Inquiry that, throughout his career, transfusion was regarded as a rarely-used but valuable resource that was to be used sparingly due to low supply and cost.

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In cases of acute massive blood loss, the amount of blood required is normally determined by the volume of blood lost. Patients who refuse transfusion in the context of haemorrhage have a six-times increased risk of maternal death.

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The threshold of when to transfuse during a postpartum haemorrhage has evolved from a haemoglobin level of 10g/dl in 1982, to 8g/dl in 2007 and to 7g/dl by 2019.

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Anaesthetists viewed the risk-benefit balance of acute transfusion as overwhelmingly weighted toward benefit compared to the small risk of infection, which posed no significant barrier to the use of blood or blood products.

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Iron was an alternative for the treatment of anaemia following childbirth, however it was slower than blood to have a beneficial impact and some patients poorly tolerated it. Ferric carboxymaltose infusions ("Ferinject") have been increasingly used recently and offered as an alternative to transfusion.

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The safety of transfusions was actively considered prior to the emergence of HIV, and centred on issues of blood-type incompatibility and other complications rather than the risk of viral infection, which was perceived to be a smaller risk.

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Doctors became more aware of viral infections after a junior doctor at King's College Hospital developed acute Hepatitis B and died from liver failure from sustaining a needlestick injury.

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A conservative approach to the administration of blood for some clinician arose from an academic interest in best transfusion practice and concerns over patient safety.

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Acute blood loss during pregnancy generally arose from delivery or was due to a haemorrhage before, during or after delivery (with postpartum haemorrhages occurring when the placental bed bleeds extensively if the placenta does not detach correctly during childbirth).

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The threshold for transfusion due to a postpartum haemorrhage was previously 500ml of blood loss but is now usually 1,000ml.

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Transfusions were commonly given to women after labour to help them recover quickly so that they could care for their baby, and also because they were thought to be anaemic after birth.

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Professor Steer was conservative in giving blood transfusions to pregnant or postpartum women, preferring to use blood transfusions to remedy acute blood loss rather than anaemia like some of his clinical colleagues.

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Although Professor Steer explored the possibility of autologous blood transfusions for women having elective caesarean sections in the 1980s and early 1990s, but found that there were no obvious or appropriate alternatives to blood transfusion in maternity care.

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Red cell salvage was introduced at the Chelsea and Westminster Hospital in the early 2000s, and by 2006 the UK Obstetric Anaesthetists Association had established that cell salvage was used in 38% of maternity units.

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