Infected Blood Inquiry Report Oversight and Assurance Group minutes: November 2024

Attendees and apologies

Members

• Christine McLaughlin, Co-Director Population Health, Scottish Government (SG), Chair
• John Dearden, Chair, Haemophilia Scotland
• Dr Tracey Gillies, Medical Director, NHS Lothian and representing the Scottish Association of Medical Directors
• Tommy Leggate, Manager, Scottish Infected Blood Forum
• Professor Marc Turner, Director, Scottish National Blood Transfusion Service (SNBTS)

Guests

• Simon Watson, Medical Director, Healthcare Improvement Scotland (HIS) (representing Robbie Pearson)
• Mark Dexter, Head of Strategic Policy Development (Education) General Medical Council (GMC)
• Ian Somerville, GMC
• Lindsay Donaldson, Deputy Medical Director, Quality and Safety, NHS Education for Scotland (NES)

Secretariat

• Sam Baker, Unit Head, Organ and Blood Donation, Infected Blood and Abortion Policy, SG
• James How, Team Leader, Blood, Organs and Tissue, SG
• Laura Mackay, Policy Manager, Blood Donation and Infected Blood, SG

Apologies

• Professor Nicola Steedman, Deputy Chief Medical Officer (DCMO), SG
• Dr Emilia Crighton, Director of Public Health, NHS Greater Glasgow & Clyde, representing Directors of Public Health
• Robbie Pearson, Chief Executive, Healthcare Improvement Scotland (HIS)
• Lynne Anderson, chair, Scottish National Blood Transfusion Committee (SNBTC)

Items and actions

Minutes of previous meeting and actions

The Chair welcomed attendees to the fourth meeting of the Oversight and Assurance Group (OAG) and asked if the draft minutes of the previous meeting could be agreed.

Some minor revisions were requested as follows:

• On Action 6, on peer reviews of haemophilia centres. An additional line be included making it clear that in respect of the letter to the five Health Boards with haemophilia centres, references to reviews should be construed to cover both past and future reviews.
• On item 4.1 on monitoring liver damage for those with hepatitis C (recommendation 6). Paragraph 6 should be amended to be clear it relates to patients who have achieved a sustained viral response; and
• Paragraph 9 should be amended to reflect that many of those infected via NHS blood do want ongoing monitoring due to their particular anxiety about what has happened to them.

It was agreed the minutes would be updated and re-circulated to those who had requested changes for comment before publication.

The Chair ran through progress on actions from the previous meeting:

Action 1: Liver monitoring for patients who had hepatitis C - A fuller paper outlining the approach to services and what further interventions may be required will be presented at a future OAG early in the new year. Action in progress - For discussion at the February OAG. Further advice has been commissioned from the Scottish Health Protection Network Viral Hepatitis Strategic Group in light of the OAG discussion.

Action 2: Request clarification from the IBI about the recommendations (on liver monitoring). Action complete. Following discussion with the IBI, they sent a clarification letter on 16 October 2024. This letter will be considered as part of Action 1.

Action 3: Patient safety. A fuller scoping paper will be presented at the February OAG focussing on recommendations 4a, b, c and e and 10a(i), demonstrating how the recommendation can be implemented. Action in progress - Paper to be presented to OAG in February.

Action 4: Patient Blood Management. The OAG will write to Health Boards to ask them to take steps to ensure compliance with the tranexamic acid (TXA) recommendation and to encourage further work to monitor their use of blood. Health Boards would be asked to provide confirmation that they were complying with recommendation 7(a)(ii) in particular. Action complete - Letter issued by Director of Population Health and Deputy Chief Medical Officer (DCMO) on 05 November 2024. The letter seeks responses by the start of December on transfusion governance and by the end of January 2025 on TXA. It was suggested that thought should be given to what “good enough” looks like as a response on using TXA and noted this could be considered further once the group had seen how Boards responded.

Update on proposed UK Government (UKG) report on implementation of the Infected Blood Inquiry’s (IBI’s) recommendations

The OAG was reminded, as per previous discussions, that the UKG planned to publish a report in December outlining progress made so far in implementing the IBI’s recommendations, in line with recommendation 12 of the IBI. The draft OAG paper outlining the proposed Scottish contributions to this UK report was discussed. The positions set out in this paper were preliminary at this stage.

As proposed by UKG, the UK report would confirm whether UKG and Devolved Governments accept individual recommendations in full or in principle. Where recommendations are “accepted in principle” the governments recognise the rationale for actions and want to deliver change. However, further work is required to confirm exactly how the recommendations will be addressed. It was noted that a further UKG report was expected by May 2025.

The OAG discussed each of the recommendations directed at Scotland and noted the reasons for either accepting them in full or in principle.

In respect of recommendation 2 on memorialisation, the point was made that issues including planning consent require further work and so it might be better not to refer to a specific target date in the UKG report. The point was also made that whilst the Scottish charities have already raised substantial funds for the memorial, more might be required.

On the proposed response to recommendation 4c), it was noted that HIS was working closely with Scottish Government (SG) policy colleagues on next steps. Whilst the principle of the recommendation on safety management systems was correct, the issues raised in the report were in relation to England and so HIS was considering whether its existing quality and safety management processes could be reinforced to deliver the recommendation. In respect of sub recommendation 4d) on the digitisation of patient records, the OAG also suggested that a clearer timeframe for the proposed digital maturity assessment would be helpful.

On recommendation 5 on ending the defensive culture in the civil service and Government, the OAG noted that this recommendation was largely for UKG to lead on. Further text would be added to the Scottish contribution to the report on the proposed changes to the Scottish Ministerial Code. And it was noted that there was as yet no confirmation about whether the UK ‘Hillsborough’ Bill on duty of candour would extend to Scotland.

In respect of recommendation 6 on monitoring liver damage for patients infected with hepatitis C, it was noted that further advice from clinicians has been commissioned following previous discussions in the OAG and that this advice would be discussed at a future OAG meeting. Clinicans are, however, happy to accept the recommendation in principle at this stage.

The OAG also discussed monitoring for patients infected with hepatitis B (HBV). Those with chronic HBV should receive ongoing monitoring in line with previous clinical advice, which means that those who want such monitoring should be getting it. It was agreed this could be referenced in the UK report.

In respect of recommendation 7c on transfusion laboratories, staffing issues were complicated by the geography in Scotland. SNBTS has also taken over management of some of the blood banks and some blood banks in the Highlands and Islands are very small. Hence, further consideration will need to be given to implementation here and this is being considered initially as part of a remote and rural workstream, reporting to the SG-NHS Planning and Delivery Board. In respect of sub-recommendations 7(f)i-iii on establishing the outcome of every transfusion, the current SNBTS “Account for Blood” system has been in place since 2010. SNBTS is currently working on a paper to propose what changes should be made to this system to implement this sub recommendation.

In respect of recommendation 9 on protecting the safety of haemophilia care, it was suggested that this recommendation should be accepted in full by SG as it has already been agreed that the OAG Chair will write to the relevant Health Boards to ask them to give favourable consideration to the outcome of current and future peer reviews. This was agreed.

In respect of recommendation 10 on giving patients a voice the issue of funding for charities was being considered with a view to seeking to take a four nations approach. In respect of sub-recommendation 10(a)iv on supporting thalassaemia and sickle cell patients it was agreed that sickle cell disease is becoming more common in Scotland and that Scottish National Blood Transfusion Service (SNBTS) should be involved in further consideration of this recommendation given their role in providing specialised blood components for these patient groups.  

Consideration of IBI recommendations

Learning from the Inquiry (recommendations 3(a) and (b))

The OAG received a verbal update from Mark Dexter, Head of Strategic Policy Development (Education), General Medical Council (GMC), on work to address recommendations 3a and b and 7d and Cabinet Office plans for the December update to Parliament. Mark also circulated a supporting update paper which had been submitted to Department of Health and Social Care’s (DHSC’s) recommendations board and was being shared with government officials and the statutory education bodies across the four nations.

It was reported that all UK medical schools and Royal Colleges had been written to about implementation of these recommendations and feedback had already been received from about twenty of them so far - a summary of responses received had been included in the GMC’s update paper. Staff in all UK nations’ statutory education bodies and blood services were now involved in a combined four nations working group taking forward these recommendations, along with recommendation 7(d) on undergraduate and postgraduate training for staff in relation to transfusions.

The four nations group will map training and educational resources with the aim of disseminating them across all NHS networks; it was noted that SNBTS already has significant resources available that can be considered as part of this. It was confirmed that NES was involved in this group and agreed with the GMC on how the work was progressing.

The OAG welcomed GMC’s update but asked them to ensure they consider international graduates who come to work in the UK and questioned whether checkpoints were being put in place to ensure they were properly trained as well. It was agreed that this was a good opportunity to rationalise material and GMC would feedback and inform on safeguards. It was agreed that the IBI was a catalyst for change going forward. The Chair suggested that it would be helpful to have an update on the training and requested that NES provide an update in early 2025.

Memorialisation (recommendation 2)

The OAG received an update on progress with the Scottish memorial. It was reported that good progress had been made with the City of Edinburgh Council and a meeting with campaigners and the Council’s Head of Parks and Head of Arts was being arranged for December to discuss potential locations, such as Regent Road Gardens, Inverleith Park or Atholl Place Gardens. It was reported that while Edinburgh was the preferred location, further discussions with Glasgow City Council would also be explored if needed.

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

The Chair confirmed that that members would be canvassed for a suitable date and a doodle poll would be circulated to agree a date in the New Year for the next meeting.

Any other business

No other business was raised.

Summary of action points

Minutes of previous meeting and actions

Action 1: update and recirculate the minutes for comment. Post meeting note: action complete. The minutes were amended and re-circulated to those who raised points for comment before being published on the Scottish Government website.

Draft Scottish Government contributions to UK report

Action 2: Update the draft SG contributions to address the points raised above in the draft report.

Learning from the Inquiry (recommendations 3(a) and (b))

Action 3: Provide an update in the spring on progress regarding training.