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The Inquiry has heard evidence of a large level of under-reporting, so that data important for public safety is never recorded in any document or on any system even before questions of its retention or destruction arise.

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Dr Alison Cave told the Inquiry she thought we were "some way off" having a UK-wide linkage of GP and hospital care.

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Despite the fact that transfused blood in all parts of the UK is considered to be safe, witnesses had concerns about whether compliance with best practice standards could be better, and believe that it should be

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In his oral evidence to the Inquiry Professor Mark Bellamy stated that with regard to transfusion of red cells in his own area of clinical practice, it was "better not to transfuse to 'normal' blood count values but to adopt a lower target, a restrictive transfusion threshold".

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In his oral evidence to the Inquiry Professor Mark Bellamy stated that although there was a small working group of clinicians and SHOT staff, SHOT's steering group was drawn from a wide range of individuals from the Royal Colleges and professional bodies and it was independent of government.

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The annual reports of SHOT contained recommendations for transfusion safety.

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Professor Bellamy, the present SHOT Steering Group chair, described the extent to which recommended measures are implemented as well as the response rates to the surveys as "variable".

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In his oral evidence, Professor Neuberger stated that SHOT's recommendations were accepted and implemented for additional testing for Hepatitis B infections.

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Professor Bellamy in his oral evidence stated that he thought that mandating Trusts to have a designated person in place to report haemovigilance matters might be possible but that If such a post were not mandated, he feared that what would then be an optional position could be an early victim of cuts.

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Professor James Neuberger was "very much in favour" of legally mandating reporting, and said that having someone statutorily responsible would be a "very useful start."

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Dr Cave was concerned to encourage a system-wide culture for reporting events, and feared that having a single person appointed as responsible might take away from a sense of collective responsibility. Making reporting as easy as possible seemed to her to be a critical factor in making an impact

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In her oral evidence to the Inquiry, Dr Sarah Meekin reported: "we often hear people talking about people feeling like lower-class citizens in terms of how they feel that they were treated, and any lack of parity contributes to those feelings and to that experience, and so that has a sort of ongoing psychological impact as well".

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In his oral evidence, Professor Melville stated that medical staff are required by the GMC to undergo annual appraisal which is linked to revalidation.

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Professor John Dillon, clinical lead for Hepatitis C in NHS Tayside, described the approach to treatment of Hepatitis C in Scotland.

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Inquiry Chair’s final letter

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On the third day of the Inquiry's preliminary hearing, Mr Bradley, solicitor for the Haemophilia Society, made his opening statements in relation to the pharmaceutical companies, stating the product caused infections in the UK.

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On the third day of the Inquiry's preliminary hearing, Steven Snowden QC made submissions on behalf of those represented by Collins Solicitors.

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A witness described the positives of the use of concentrates for home treatment including quicker treatment.

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Considering the evidence, there was always likely to be sufficient cryoprecipitate capable of being produced. However, clinicians, and no doubt many patients too, wished for the added advantages which factor concentrates offered, particularly in terms of home therapy.

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