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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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Dr David Paintin produced research that demonstrated plasma volume expanded faster than red cell volume during pregnancy, and that the concentration of red cells fell.

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In Relation between maternal haemoglobin concentration and birth weight in different ethnic groups it was noted that during pregnancy, plasma volume expands faster than red cell volume and the concentration of red cells falls.

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Although viral infection was a serious concern to clinicians, other risks of blood transfusion were more prevalent and in terms of early mortality, more pressing.

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Dr Jonathan Wallis was of the view that the administration of single and two-unit transfusions could be appropriate outside paediatrics in the case of very small adults, adults with an unstable cardiac state where volume overload is a concern, and where haemoglobin levels ought to be raised by only 1g/dl.

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At Newcastle, new doctors had teaching on the mechanics of transfusion at induction, and a further session on the appropriate use of blood as part of their mandatory training during their period of stay. Copies of the transfusion guidelines and handbooks were were widely circulated.

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Tranexamic acid started to be used regularly in several areas of surgery.

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Patients who had given autologous blood pre-operatively were found to be more likely to require per-operative transfusion because they arrived at surgery more anaemic than if they had not donated blood.

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Uptake on autologous blood transfusion was not high as the practice was of very limited benefit to the patient, and it was discontinued in the 1990s.

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Audits on blood use often resulted in a fall in blood component usage.

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At the Freeman Hospital in Newcastle, the role of transfusion nurses was introduced and one of their roles was to investigate reports of adverse reactions to blood transfusions.

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HTCs were multi-disciplinary committees which sought to draw together different medical specialities to improve transfusion standards, discuss national and local guidelines and audits.

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SHOT was a model for haemovigilance organisations worldwide.

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In his written evidence to the Inquiry, Dr Jonathan Wallis noted that although there has been a considerable reduction in the use of red blood cells in the last 25 years, there is still considerable work to be done as 20-30% of transfusions in major specialisms are currently given outside the national guidance.

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Dr Gillon carried out a controlled clinical trial of autologous cell salvage in cardiac surgery in Scotland and was the Chairman of the Working Party on Autologous Transfusion in the mid 1990s.

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Only 133 patients had been referred for autologous cell salvage in Scotland, resulting in 90 patients donating 171 units of blood for their own use by 1996. Although the number of referrals briefly doubled in 1997 due to clinical referrals, demand for the services became low and the autologous transfusion service was reduced to a single provider in Scotland.

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Red cell salvage became more widely available. A study of intraoperative cell salvage in cardiac surgery at The Edinburgh Royal Infirmary found the procedure was shown to be feasible and safe and it became an accepted part of surgical practice.

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Senior individuals working in the transfusion services focused on the issue of blood transfusion after the establishment of the Consumer Protection Act 1987 and the introduction of the European Directive on blood.

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In his written evidence to the Inquiry, Professor Michael Murphy noted that "best transfusion practice" meant that a transfusion should only occur when the benefits outweigh the risks, and that alternatives should be considered and used where appropriate.

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