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In his oral evidence, Professor Neuberger stated that SHOT's recommendations were accepted and implemented for additional testing for Hepatitis B infections.

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Professor Bellamy in his oral evidence stated that he thought that mandating Trusts to have a designated person in place to report haemovigilance matters might be possible but that If such a post were not mandated, he feared that what would then be an optional position could be an early victim of cuts.

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Professor James Neuberger was "very much in favour" of legally mandating reporting, and said that having someone statutorily responsible would be a "very useful start."

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Dr Cave was concerned to encourage a system-wide culture for reporting events, and feared that having a single person appointed as responsible might take away from a sense of collective responsibility. Making reporting as easy as possible seemed to her to be a critical factor in making an impact

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The 1963 edition of "Notes on Transfusion" reiterated the statement that a transfusion should never be given without a definite indication, adding that this was in "the patient's interests" and due to unlimited blood supplies and an ever-growing demand for blood it must not be used unnecessarily.

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The 1963 edition of "Notes on Transfusion" highlighted that the use of blood transfusion to correct "moderate or slight degrees of anaemia" was "unjustifiable" where there were slower but safer methods available.

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The Advisory Committee on the Safety of Blood, Tissues and Organs' planned to set up a working group to agree principles for future lookback investigations.

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The bulk of the guidance governing best transfusion practice in the UK was produced in the 1990s onwards with the main publication, known as the "Red Book", being first published in 1989.

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As at 2000, there was no published data about the frequency of autologous transfusion in the UK.

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National bodies, rather than just individual clinicians, began to produce guidelines on transfusion to address specific scenarios in particular specialities.

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Part of the Standing Advisory Committee on Transfusion Transmitted Infections' remit involved commissioning, conducting and coordinating trials for new technology involved in screening blood.

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The 1984 "Textbook on Surgery" highlighted that "blood transfusion carries some risk and alternative methods should be chosen whenever possible."

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"Principles and Practice of Surgery", described the transmission of viral hepatitis as "the most serious and frequent complication of the administration of blood and blood products ... The best preventative measure is to avoid unnecessary transfusion."

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The establishment of the Consumer Protection Act 1987 and the introduction of the European Directive on blood led senior individuals working in the transfusion services to focus on the issue of blood transfusion.

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Dr Contreras reported that Hospital transfusion committees were "now being established" in five major hospitals which the North London Blood Transfusion Centre supplied, following an audit which had shown very disappointing results.

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In 1989, a working party of the British Medical Association recognised that there was a need for further research into the indications for transfusion to develop professional consensus on the indications for prescribing blood.

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A working party of the British Medical Association noted that there was a need for more teaching time on transfusion in the medical undergraduate curriculum and in formal postgraduate courses.

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Sir Kenneth Calman described that there had been several recent high profile healthcare issues which focused on the safety and availability of blood.

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Sir Kenneth Calman wrote that "good evidence" had been produced that "significant unnecessary blood transfusion" could be avoided

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Sir Kenneth Calman thought the Serious Hazards of Transfusion report "raised the profile of blood safety amongst clinicians and the public".

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