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The House of Commons Constitutional Affairs Committee 'Reform of the coroners' system and death certification' found the system in England and Wales unfit for a modern society without significant reforms.

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The Coroners Act 1988 provided that the coroner had a power to request a post-mortem without an inquest taking place, other than in cases of a violent or unnatural death, or a death in prison.

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The Coroners Act 1988 provided that within five days of the completion of the inquest, the coroner was obliged to send to the registrar of deaths a certificate setting out information concerning death, the particulars of death required by the Births and Deaths Registration Act 1953 and specify the time and place at which the inquest was held.

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Section 28 of the Coroners (Investigations) Regulations 2013 provided that a coroner may make a report on action that can be taken to prevent further deaths. Such a report was to be issued to people or organisations "who the coroner believes may have power to take action" and they must respond explaining what actions have been taken to prevent risk.

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Rule 23 of the Coroners (Practice and Procedure) Rules (Northern Ireland) 1980 provided that a coroner may report to "the person or authority who may have power" to take action "to prevent the occurrence of fatalities similar to that in respect of which the inquest is being held."

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The Ministry of Justice Guidance for registered medical practitioners on the Notification of Deaths Regulations stated that medical practitioners should notify the coroner when the death was due to the use of a medical product.

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Lord Justice Simon Brown suggested in R v Inner London North Coroner, ex parte Touche [2001] that there was a powerful case for holding an inquest "whenever a wholly unexpected death, albeit from natural causes, results from some culpable human failure") concerning a death which occurred in hospital possibly as a result of hospital treatment.

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Section 3 of the The Notification of Deaths Regulations 2019 provided that medical practitioners are to notify a coroner if it is suspected the person's death was due to a poisoning, exposure to a toxic substance, the use of a medicinal product, the person undergoing a medical treatment or procedure, or that the person's death was unnatural.

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The Judicial Review and Courts Act 2022 provided that a coroner has the power to conduct non-contentious inquests (where no jury is required) in writing.

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A survey of 98% of NHS Trusts in England found that there was "patchy" use of intra-operative cell salvage, with 55% of Trusts using it for orthopaedic surgery.

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A survey of 98% of NHS Trusts in England found that only 17% Trusts had less than one full time transfusion practitioner.

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The National Blood Transfusion Committee published initial recommendations about how the NHS should implement the Patient Blood Management initiative.

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Better Blood Transfusion initiatives were successful in leading to a reduction of red cell usage by over 20%.

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The Transfusion 2024 plan was announced, which outlined key priorities and recommendations for clinical and laboratory transfusion practice for safe patient care across the NHS.

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SHOT has had consistently high levels of engagement.

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SaBTO published guidelines on consent.

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The Royal College of Physicians published a summary of the SaBTO guidelines on consent in their Concise Guidance series.

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A lack of compliance with giving both verbal and written information, such that national compliance is 26%. Only 64% of transfused patients had evidence of receiving one or the other.

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Dr Jean Harrison said that the RTC provided teaching and training for senior registrars in haematology in blood transfusion, laboratory and nursing staff also attended.

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Paul Mouncey's wife, Jane, was not given any indication that there was a risk from the transfusion.

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