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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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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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