Publication - Minutes

Infected Blood Inquiry Report Oversight and Assurance Group minutes: March 2026

Published: 29 May 2026
Directorate: Population Health Directorate
Topic: Health and social care
Date of meeting: 24 March 2026

Minutes from the meeting of the group on 24 March 2026

Part of

Infected Blood Oversight and Assurance Group

Attendees and apologies

Members present

Richard Foggo, Director, Population Health, Scottish Government (SG), OAG Chair
Lynne Anderson, Chair, Scottish National Blood Transfusion Committee (SNBTC)
John Dearden, Chair, Haemophilia Scotland
Tracey Gillies, Medical Director, NHS Lothian, and representing the Scottish Association of Medical Directors
Tommy Leggate, Manager, Scottish Infected Blood Forum
Joy Tomlinson, Director of Public Health, NHS Fife and representing the Directors of Public Health
Marc Turner, Director, Scottish National Blood Transfusion Service (SNBTS)

Guests

Rebekah Carton, Sexual Health and Blood Borne Viruses (BBV) policy team, SG
Marion Logan, Digital Capabilities Policy, SG
Lorna McLintock, Medical Director, SNBTS
Henrik Moeller, Digital Consultant
Lynne Nicol, Deputy Director, Planning and Quality, SG
Adam Pinner, NHS Education for Scotland (NES)
Caroline Pretty, Sexual Health and BBV policy team, SG

Secretariat

Donna McLeod, Unit Head, SG
James How, Team Leader, Blood, Organs, and Tissue policy, SG
Laura Mackay, Blood Safety and Infected Blood policy, SG

Apologies

Professor Nicola Steedman, Deputy Chief Medical Officer (DCMO), SG, OAG Deputy Chair
Dr Simon Watson, Medical Director, Healthcare Improvement Scotland (HIS), representing Robbie Pearson, OAG Member
Professor Emma Watson, Executive Medical Director, NHS Education for Scotland (NES)

Items and actions

Welcome and Introductions

The Chair welcomed attendees to the eighth meeting of the Infected Blood Inquiry (IBI) Oversight and Assurance Group (OAG). He thanked Emilia Crighton (who has now retired) for her time and contributions to the OAG and welcomed Joy Tomlinson, who will attend going forward.

The Chair noted that Sir Brian Langstaff, IBI Chair, announced on 25 February that the IBI’s work will come to an end on 31 March 2026 as it has fulfilled its terms of reference.

The Chair reported that, in line with recommendation 2 of the IBI on memorialisation, the second IBI commemorative event at St Paul’s Cathedral in London would take place on 19 May 2026. However, he noted that, given the elections to the Scottish Parliament on 7 May, it may be difficult for Scottish Ministers to attend.

Minutes of Previous Meeting and Actions

The Chair noted that the minutes of the previous OAG meeting on 11 November had been agreed and published on the Scottish Government (SG) website on 15 December 2025. James How then ran through progress on the five actions from the previous meeting:

John Dearden agreed to send examples of missing text, following which the Secretariat will review the workplan. (Secretariat). Action completed: All of the information was complete within the workplan on 13 November 2025.
Scottish National Blood Transfusion Service (SNBTS) to continue to participate in the UK-wide benchmarking group work and to report back to OAG as necessary (Lorna McLintock SNBTS). Update given at the meeting within paper 4.
SNBTS to provide a paper to the Secretariat outlining the proposals and requirements for a “once for Scotland” approach for blood transfusion in NHS Scotland and the Secretariat would assist in providing advice about next steps in its agreement (Lorna McLintock SNBTS). Update given at the meeting within paper 4.
SNBTS to provide a Strategic Needs Assessment to Secretariat to support the approach on hospital blood bank sustainability, whilst waiting for the Scottish Planning Board to consider the paper (Lorna McLintock SNBTS). Update given at the meeting within paper 4.
NHS Education for Scotland (NES) agreed to provide a business case to the Secretariat setting out the level of further funding required and what it would cover (Emma Watson NES). Action completed: Funding has been agreed with NES to take forward recommendation 3 and parts of recommendation 7. NES will update the OAG as they progress though the work.

Consideration of IBI recommendations

Patient Safety update (recommendations 4a, b, c and e and 10a(i))

Lynne Nicol (SG) updated on progress on the patient safety recommendations. The review of the operation of the duty of candour in healthcare in Scotland was completed in December 2025. A resulting programme of work is being developed to be progressed in the new parliamentary term, which will take into account the findings of the review and focus on duty of candour, adverse events, NHS complaints, openness, and learning. Public engagement was undertaken through HIS’s Citizens’ Panel. A draft report is being finalised which will be published. The key risk is the variation in processes across Boards, governance, staff confidence, and public awareness, all of which require further consideration. Securing the engagement of key stakeholders will be essential to ensure the resulting programme of work delivers meaningful impact. Lynne also reported on ongoing work around safety management systems (SMS), with a suite of measures around safety outcomes.

The Chair stressed the importance of the offer to engage stakeholders and the importance that SG’s Health and Social Care Management Board attaches to responding to all Inquiries. John Dearden asked for further clarity about the approach being taken. Lynne said the aim of this work was to take a more proactive approach, not just responding to concerns that are judged to be “serious.” The OAG noted the paper and confirmed agreement with the proposed approach. The OAG also agreed that an update paper should be circulated ahead of the next meeting.

Action 1: An update paper reporting further progress on the patient safety recommendations, including details of the SMS workplan, to be circulated to members ahead of the next OAG (Lynne Nicol, SG).

Patient Records (recommendation 4d(i)) Digital Maturity Assessment Survey update

Marion Logan (SG) updated on progress on meeting the recommendation on digitisation of patient records, which will be done using SG’s existing Digital Maturity Assessment (DMA). Using this process, NHS Boards and Social Care Partnerships are asked to submit an update on their progress by the end of July of each year. This is a publicly reported process with a summary report for the 2025 update due to be published. By the end of 2027 SG will be able to report on the extent of success in meeting the recommendation and any specific findings in the areas detailed. A related development is the national programme to open up patient access to their records which is now underway via the rollout of MyCare, to ensure people can reliably access, understand, and trust the accuracy of their online health and care information. Volunteers are being sought to attend a dedicated workshop to consider development of a set of indications to meet the requirement in the recommendation “to assess extent of progress on ability to identify and correct errors on digital records.” Lorna McLintock said that SNBTS would like to be involved in the digital maturity assessment questions relating to transfusion.

In discussions, John Dearden asked for clarity on the extent to which the work being undertaken satisfied the recommendation. Tracey Gillies said that, although this looks to be useful work towards making it more transparent to people as to how they can access their records and correct errors, we will need to be further assured about what the new systems can and cannot do. Henrik Moeller clarified that one of the key hurdles to users correcting errors in their records is whether the data is presented in a manner that is comprehensible to laypeople. To understand this aspect, any programme like MyCare needs a user monitoring process that assesses whether errors are being accurately identified and successfully corrected.

James How clarified that the DMA process will be the mechanism for meeting this recommendation, which says there must be a formal audit of the digitisation of patient records by 2027. There is the opportunity to review some of the questions within the DMA to see whether there needs to be further refinement. The DMA process will tell us about the level of success and next steps required. The OAG agreed this was a useful and important area to explore and noted the update on progress, particularly on allowing patients to correct errors in their records.

Action 2: Marion Logan to provide a further update to James How in the Secretariat for passing on to the OAG about next steps on the work to meet this recommendation, including details of the proposed workshop; in addition, a further progress update would be considered for inclusion on the agenda of the next OAG meeting (Marion Logan, SG)

Monitoring liver damage for people who were infected with Hepatitis C recommendation 6 - update on progress

Rebekah Carton and Caroline Pretty (SG) provided an update on progress on the implementation of this recommendation. Public Health Scotland (PHS) had been tasked to examine the available data on care provision and health outcomes for affected patients. Unfortunately, the findings were inconclusive due to data complexity and quality issues. Other methods of data analysis were considered, however PHS recommended that a targeted case note review could provide clearer evidence. The detailed case note review of these patients found they had all been appropriately assessed and followed up for liver damage, with the exception of where they had defaulted from follow up. As previously agreed at the OAG, officials asked the Viral Hepatitis Strategic Group to take forward a review of Hepatitis C Virus (HCV) clinical guidelines. This was delayed due to clinician capacity, but is expected to be completed by the end of March 2026.

Officials have also carried out a survey examining current HCV and Hepatis B Virus care pathways in Health Boards across Scotland. Based on replies received so far, the survey shows that, while there was some variation around clinical guidelines, they routinely offer fibrosis assessment using non-invasive methods, and routinely offer ultrasound for those with advanced fibrosis or cirrhosis. Work with Hepatitis Leads will be undertaken to consider how the variations can be aligned going forward. Finally, a helpful meeting with stakeholders was held on 27 February to discuss ongoing monitoring and, based on feedback, there is now an offer from SG to review appointments for all those patients who have not had the opportunity to speak with a clinician to help understand their care.

John Dearden agreed that stakeholders had helpful discussions with SG on these issues. He was content with the outcomes. The only remaining issue of concern is what the final review of clinical guidelines might say. How will those guidelines work in relation to this paper? Rebekah agreed to circulate the final review to the OAG once published for further consideration. Tracey Gillies wondered whether we need standards, rather than guidelines, making the point that language was important here. It is good news that most affected individuals are already receiving care. Those who receive the offer of a review appointment need to have clear advice about risk stratification. Caroline said that was an important point and would be considered.

Rebekah clarified that everyone will have the chance to opt in to be reviewed. She noted that some medical records remain paper‑based and therefore it would not be appropriate for a review appointment to take place without a clinician first having an understanding of the individual’s history. For this reason, an initial review of records and a written summary would be undertaken. Some individuals may consider this sufficient and not require a face‑to‑face appointment, but where a meeting is requested, this would be facilitated. On this basis, the OAG confirmed it was content with this update.

Action 3: A paper to update OAG members on the outcome on the review of the hepatitis C clinical guidelines will be circulated once published (Rebekah Carton/Caroline Pretty, SG)

Patient Safety: Blood transfusions recommendations 7a(iii), b, c and f – update on progress

Lorna McLintock provided an update on progress made on implementation of these recommendations. In relation to recommendation 7a(ii), Lorna advised that revised National Institute for Health and Care Excellence guidance to broaden the use and scope of tranexamic acid was issued in February 2026. This revised guidance has been tabled for information at SNBTC with the plan for Chairs of the hospital transfusion committees (HTCs) to share the information and make sure there is broad awareness in Boards. SNBTS Transfusion Practioners have also disseminated this to hospital transfusion teams and HTCs. The OAG confirmed it was content with this approach.

In relation to recommendation 7(b), Lorna reported that there is an internal SNBTS transfusion plan. It was agreed at the previous OAG that any Scotland-wide transfusion strategy should be progressed via Board Chief Executive Officers (CEOs). This is currently paused while a new Chief Executive for Public Services Delivery Scotland is onboarded. The OAG Chair confirmed that there was no stipulation that any such strategy should be agreed by CEOs. It could also be agreed by medical or nurse directors, whoever would be best. It was agreed that outputs from the Serious Hazards of Transfusion (SHOT) reports should be used to inform this and progression of this work was in part dependant on this.

In relation to recommendation 7(e) - that all NHS organisations across the UK have a mechanism in place for implementing recommendations of Serious Hazards of Transfusion (SHOT) reports, which should be professionally mandated, and for monitoring such implementation - Lorna reported that the SHOT gap analysis initiated by the OAG in August 2025 was ongoing. Tracey Gillies said that it would be important to see what the SHOT gap analysis, which was a big piece of work for Boards to do, says. The data is likely to be varied. James How said that SG would need expert help in analysing the Board returns. Lorna agreed that SNBTS could help but that other input, for example from HIS, would be needed. The OAG Chair agreed that we need to be clear what the analysis looks like, who should be involved, and what the timeline is. It was agreed that SG and SNBTS would clarify offline.

Action 4: Secretariat to liaise with SNBTS on how to analyse SHOT reports (Secretariat)

In relation to recommendation 7c - that transfusion laboratories should be staffed (and resourced) adequately to meet the requirements of their functions - Lorna reported that a Strategic Needs Assessment for hospital blood banking had been completed and submitted to SG for consideration as agreed at the previous OAG. Marc Turner reiterated that staffing in the blood banks was becoming a real issue in some areas and was not sustainable in the long-term. The OAG agreed that good progress had been made on the action agreed at the previous OAG on this recommendation.

OAG workplan

James How provided a brief update on the OAG workplan, which reflects the current progress of recommendations, and asked the OAG to notify the Secretariat if any amendments were required. James highlighted that, as noted in the actions of the previous meeting, NES funding had been approved and there was now a clear way forward with recommendations 3 and 7(d). Tracey Gillies noted that significant time was required by Boards to support compensation applications from the Infected Blood Compensation Authority (IBCA). James reported that SG were working with IBCA on a daily basis and that he was happy to feedback any issues.

Action 5: OAG members to feedback on any concerns regarding time requirements for compensation requests and this will be fed back to IBCA (Secretariat).

Agreement on next steps, timing of next meeting, and feedback on the meeting

The next meeting is suggested for late September or early October, with dates to be confirmed by the Secretariat. James invited members to suggest any additional topics for inclusion on the agenda and notify the Secretariat.

Any other business

There was no other business.

Summary of action points