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There was a move towards undertaking audits at individual hospitals and on a national scale. Audits were also undertaken at RTCs.

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Dr Angela Robinson described that in the 1990s if a regional health authority was not prepared to fund a recommendation made by SACTTI "it was then difficult to implement it".

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Dr Robinson emphasised that the blood service has always recognised that it has a role in advising and educating clinicians as to the risks of blood and blood products and as to appropriate use of blood and good transfusion practice. Blood components should only be used when strictly necessary and in the absence of alternatives.

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Dr George Galea described that he recalls teaching medical students about the risks of transfusions and that "the safest blood is the blood that's not given." He told students not to "go overboard" with using blood.

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The implementation of maximum surgical blood ordering schedules at the Aberdeen Royal Infirmary led to a reduction in the number of unnecessary whole blood transfusions as well as to a reduction in the number of transfusions per operation, which reduced the risk of adverse events associated with blood transfusions.

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Patients with leukaemia, lymphoma or multiple myeloma often required a significant number of transfusions, and often would not have survived without them.

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Patients with leukaemia were often transfused with whole blood or red cell concentrates, and platelet concentrates were given to control bleeding associated with thrombocytopenia or because platelet levels had dropped.

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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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