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Lesley McEvoy received a blood transfusion at Staincliffe Maternity Hospital.

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Susan Dennison received a blood transfusion at the Peterborough Hospital. She gave evidence to the Inquiry that "The doctor did not say the word 'transfusion', just that I needed some blood. I did not know that I had received a transfusion at the time, let alone what the risks of receiving one might be. I simply followed the doctor's advice as I assumed that he knew what I needed in order to be able to take good care of my daughter."

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One man, who was infected with Hepatitis C, was injured while working on an offshore rig. He suffered a broken hip, pelvis and left arm as well as pelvic abrasions and cuts. He was given the blood transfusion when unconscious.

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Fiona Crawford was diagnosed with acute myeloid leukaemia and underwent chemotherapy at the Edinburgh Royal Infirmary.

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Maureen Drane underwent a hysterectomy and was transfused with two units of blood. Her widower has told the Inquiry that following the surgery he and his wife were told by clinicians that she had received a blood transfusion and that she "could have possibly managed without having the blood transfusion, but would have taken a little longer to recover."

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Terri Kuman described that her husband, Cem who was infected with Hepatitis C from blood transfusions was not fully informed of the link between transfusions and blood borne diseases.

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Mary Heath described that her husband was infected with Hepatitis C during treatment for acute myeloid leukaemia. This treatment was a 'do or die situation' that was left it in the hands of the experts.

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Charles Massey described that until the 1990s the role of the GMC in regulating the actions of doctors in practice was limited.

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Charles Massey described that there were no specific powers available to the GMC to approve or intervene in postgraduate training until 2010, although the GMC made recommendations.

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Charles Massey described that during the 1970s and 1980s there was no mandatory requirement for clinicians to undertake continuing professional development.

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Charles Massey described that doctors were required to undergo a two-year foundation programme after graduation and then to undertake speciality training. The Specialist Training Authority was established in 1995, followed by the Postgraduate Medical Education and Training Board in 2005, which merged with the GMC in 2010.

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The UK CMOs hosted a symposium at St Thomas' Hospital. This was attended by transfusion experts, clinicians, NHS managers and health authority chief executives from across the UK.

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A draft health services circular made a series of recommendations that were "very much a first step along the way to better blood transfusion".

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In Northern Ireland, updated Better Use of Blood in Northern Ireland guidelines was issued.

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The Births and Deaths Registration (Northern Ireland) Order 1976 stated that where a person dies "as a result of any natural illness for which he has been treated by a registered medical practitioner within twenty-eight days prior to the date of his death", that medical practitioner shall sign a certificate stating "to the best of his knowledge and belief the cause of death".

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Section 51(1)(c) of 9 Registration of Births, Deaths and Marriages Regulations 1968 specified the forms to be used and details required for death registration. A report to the coroner was required where there was a gap of more than 14 days between the last doctor's attendance and death.

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The Births and Deaths Registration Act 1926 allowed the coroner to register a death in England and Wales.

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The judgment in Lopes de Sousa Fernandes v Portugal set out that Article 2 of the European Convention on Human Rights (the right to life) is engaged in medical contexts where systemic or structural dysfunction can be demonstrated, rather than mere negligence.

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The judgment in Fernandes de Oliveira v Portugal held that a hospital failed to comply with its supervision obligations to a mentally ill patient who committed suicide under its care and this was a violation under Article 2 of the European Convention on Human Rights (the right to life).

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The judgment in R (Maguire) v HM Senior Coroner for Blackpool & Fylde and Another established that states have a positive obligation to take appropriate steps to safeguard the lives of those in their jurisdiction as well as a procedural obligation regarding investigation and the opportunity to call state authorities to account for potential breaches.

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