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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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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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