Infected Blood Oversight and Assurance Group Minutes: November 2025

Attendees and apologies

Attendees

• Richard Foggo, Director, Population Health, Scottish Government (SG), Oversight and Assurance Group Chair
• Professor Nicola Steedman, Deputy Chief Medical Officer (DCMO), SG, Oversight and Assurance Group, Deputy Chair
• Dr Emilia Crighton, Director of Public Health, NHS Greater Glasgow and Clyde, and representing the Directors of Public Health
• John Dearden, Chair, Haemophilia Scotland (HS)
• Dr Tracey Gillies, Medical Director, NHS Lothian, and representing the Scottish Association of Medical Directors (SAMD)
• Tommy Leggate, Manager, Scottish Infected Blood Forum (SIBF)
• Professor Marc Turner, Director, Scottish National Blood Transfusion Service (SNBTS)
• Professor Emma Watson, Executive Medical Director, NHS Education for Scotland (NES)

Guests

• Dr Alastair McDiarmid, Consultant Anaesthetist, and representing the Scottish National Blood Transfusion Committee (SNBTC) on behalf of Lynne Anderson
• Dr Lorna McLintock, Medical Director, SNBTS
• Dr Simon Watson, Medical Director, Healthcare Improvement Scotland (HIS), representing Robbie Pearson, OAG Member

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

• Dr Lynne Anderson, Chair, SNBTC
• Robbie Pearson, Chief Executive, HIS

Items and actions

Welcome and introductions

The Chair welcomed attendees to the seventh meeting of the Infected Blood Inquiry (IBI) Oversight and Assurance Group (OAG), which was the first such meeting that he was chairing. He noted the importance of the work being overseen by the OAG and particularly welcomed the involvement of attendees representing the infected blood community, to ensure their views were taken into account in decision making. Time was taken for members to introduce themselves.

Minutes of previous meeting, actions, and workplan

The Chair noted that the minutes of the previous OAG meeting on 08 April 2025 had been agreed and published on the Scottish Government (SG) website on 10 June. James How then ran through progress on the seven actions from the previous meeting:

It was agreed the minutes of the OAG meeting on 26 February 2025 would be updated before publication:

• The minutes were updated and published on the SG website on 17 April 2025.

SG to send the note of the meeting with HS on 12 March concerning recommendation 6 to the wider OAG:

• The note of the meeting was circulated to OAG members on 15 May 2025.

SG would produce a formal communication seeking nominations for Subject Matter Experts to be involved in developing the question set for the updated Digital Maturity questionnaire:

• We are awaiting further 4 Nations discussions to progress this action. An update will be provided at the next meeting.

SG to write to NHS Boards in April with a general update on progress on the IBI recommendations, including flagging that a further letter will be sent in July in relation to recommendation 7(e):

• A Director letter was issued to all Board Chief Executives on 13 May 2025 updating on general progress on the IBI recommendations. A Director letter and monitoring spreadsheet was issued on 13 August 2025 to Board Medical Directors on recommendation 7(e) on Serious Hazards of Transfusion (SHOT) standards. Boards were asked to complete the template and return to SG by February 2026.

Discussions on recommendation 7(e) to be scheduled with Scottish Executive Nurse Directors (SEND) and Scottish Association of Medical Directors (SAMD).

• Tracey Gillies briefed SAMD on the SHOT letter in June 2025 and Deputy Chief Medical Officer (DCMO) and James How briefed SEND on 20 June 2025.

SG will write to Health Boards once any new clinical guidance in relation to recommendation 7(a)(ii) is issued, drawing attention to the implications for implementation of this recommendation .

• This action will be considered if and when the National Institute for Health and Care Excellence (NICE) issues new guidance (expected around February 2026).

As per the December report, the OAG will be provided with a draft of the Scottish contributions to the UK report on progress on IBI recommendations for information ahead of publication in May.

• The second UK report on implementation of the IBI’s recommendations was published on 14 May 2025. A Scottish summary of contributions to the report was issued to OAG members on 15 April 2525.

James How gave a brief update on the IBI OAG workplan, circulated to members ahead of the meeting. The workplan has been updated to reflect the progress on recommendations since the publication of the UK Progress Report on implementation of the IBI recommendations in May. The OAG had not met since the publication of this report, in order to give some further time for progress to be made and then considered. The intention at this meeting, and the next meeting, is to review progress made on implementation of all the Scotland-led recommendations.

Accordingly, at the next meeting planned for February or March 2026, the intention will be to focus on recommendation 4 (Patient Safety) and recommendation 6 (Monitoring liver damage for people who were infected with Hepatitis C). In respect of recommendation 4 this will give more time for progress to be made at 4 nations level. In respect of recommendation 6, this will give more time for progress to be made on work agreed during previous discussions, including with Public Health Scotland.

John Dearden noted that some items, which had previously been present, appeared to be missing from the current draft of the workplan. He agreed to forward examples to the Secretariat for review.

Action 1: John Dearden to send examples of missing text, following which the Secretariat will review the workplan (John Dearden, Haemophilia Scotland (HS), and Secretariat)

Consideration of IBI recommendations

Recommendation 7 (apart from 7(d)) – Patient Safety - Blood Transfusions

Lorna McLintock from Scottish National Blood Transfusion Service (SNBTS) briefed the OAG on the paper prepared for the meeting, presenting a detailed round up of progress made on implementation of all aspects of this recommendation. The OAG was asked to focus on the following three questions for decision.

In respect of Recommendation 7(a)(iii) - that consideration be given to standardising and benchmarking transfusion performance between hospitals in order to deliver better patient blood management - Lorna noted that the OAG had previously agreed to meet this recommendation via the letter issued by the previous OAG Chair, Christine McLaughlin, in November 2024, asking Boards to confirm that they were using the existing SNBTS clinical transfusion dashboard. All Boards have responded to this letter to confirm that they were using the dashboard.

Lorna advised that a UK-wide benchmarking group had been set up and the devolved administrations had been invited to attend. Lorna asked the OAG to consider whether Scotland should continue to participate in this work and process the delivery of the outputs from the group as they occur or continue with the processes notified to the Boards in the letter of November 2024.

There was agreement from the OAG that SNBTS should continue to participate in the UK-wide work to help identify areas of good practice and provide levels of external assurance. However, if this work led to any changes in what the OAG had previously agreed in this area, then that would need to come back to the OAG for further consideration.

It was also agreed that, not least because the OAG is not a permanent group, it could not serve as the reporting mechanism for performance against blood transfusion standards, nor could it agree any such standards. The NHS Board Chief Executives and Scottish National Blood Transfusion Committee (SNBTC) have responsibility in that respect. Alastair McDiarmid said that SNBTC was not currently resourced to take on new work in relation to reporting or agreement of standards, and this was noted.

Action 2: SNBTS to continue to participate in the UK work and to report back to OAG as necessary (Lorna McLintock, SNBTS).

In respect of recommendation 7(b) - that progress in implementation of the Transfusion 2024 recommendations be reviewed, and next steps be determined and promulgated; and that in Scotland the 5 year plan is reviewed in or before 2027 with a view to determining next steps - Lorna highlighted the differences between the NHS England and SNBTS transfusion strategies. She outlined that whilst the SNBTS transfusion strategy was already aligned with the IBI recommendations, it was insufficient alone to deliver the necessary improvements in clinical transfusion process, as responsibility for this lies with the NHS Boards rather than SNBTS.

Accordingly, Lorna said that SNBTS was asking the OAG to consider adopting a system-wide strategy and delivery plan for blood transfusion in NHS Scotland that aligns to the shared responsibility identified by the recommendations. SNBTS proposed working with key stakeholders to develop a ‘once for Scotland’ approach to improve the clinical transfusion process.

The Chair noted that the OAG could offer advice in this area but was not in a position to instruct the Accountable Officers of the NHS. Nicola Steedman agreed that the OAG has a specific function to implement the IBI recommendations and noted that the suggested approach may go beyond this. Agreement of such an approach would likely be at Board Chief Executives level. It was agreed that the OAG, in principle, supported a “once for Scotland” approach to ensure that the conditions were in place to allow for the implementation of all the elements of recommendation 7. However, a full “strategy” as such was unlikely to be required. It might be that an action plan was a better term for what was needed. The Chair concluded that the OAG would not have an ongoing role in overseeing this broader and longer term approach, but would want to note its development.

Action 3: 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 e.g. via the Board Chief Executives Group (Lorna McLintock, SNBTS and Secretariat).

In respect of Recommendation 7(c) - that transfusion laboratories should be staffed (and resourced) adequately to meet the requirements of their functions -  Lorna reported that hospital blood banks across Scotland are facing significant challenges in terms of staffing. A paper on hospital blood bank sustainability had been submitted to the NHS Strategic Planning Board (SPB), making recommendations for improvements across Scotland. However, notification had been received that it would be some time before the paper will be considered. An interim proposal of completing a Strategic Needs Assessment (SNA) of the service had been suggested, which is being used by a number of services to develop a greater understanding of the need in their specific areas to support delivery on a national population-based planning approach.

The OAG was asked to consider whether SNBTS should wait for the SPB to consider the current paper, or whether a SNA should be prepared now. Following some discussion, it was agreed that a SNA should be undertaken now by SNBTS, to add to the evidence base for taking forward this work, whilst waiting for the SPB  to consider the paper.

Action 4: SNBTS to provide an SNA to Secretariat to support the approach on hospital blood bank sustainability, whilst waiting for the SPB  to consider the paper (Lorna McLintock, SNBTS).

Recommendation 2 - memorialisation

Laura Mackay briefed on the SG paper submitted to the OAG, which provided an update on the implementation of recommendation 2. She reported ongoing meetings between SG, HS, and the City of Edinburgh Council (CEC) regarding the creation of a memorial. The CEC remains committed to delivering a memorial. An agreement in principle to progress a memorial has been granted by both the CEC’s Culture and Communities Committee and the Public Arts Panel. There are still some concerns from the Committees around the location, size, footprint, and materials of a potential memorial. The Memorial Working Group will conduct site visits towards the end of the year alongside consultants and park rangers from the CEC to assess various potential locations and look at structural considerations. The Working Group will reconvene in December.

John Dearden reported that a partial site visit had already been undertaken and potential locations for the memorial identified, including Princes Street Gardens. However, due to ground conditions, there may be a need to redesign the memorial. There will also be a requirement to tie in with the UK Memorial Committee when it is established. Tommy Leggate clarified that the Memorial Working Group mentioned above and in the SG paper should be termed the Infected Blood Scottish Memorial Working Group, made up of HS, SIBF, widows, widowers and children of those who have died, who are volunteer fundraisers. This was noted. Finally, it was agreed that the OAG would continue to be updated as progress is made and notified of any interactions with the UK Memorial Committee.

Recommendations 3(a) and (b) and 7(d) - Learning from the Inquiry

Emma Watson presented the paper prepared for the OAG, giving an update on the implementation of these recommendations. She advised that NHS Education for Scotland (NES), in partnership with SNBTS, is developing an education strategy aligned with the IBI recommendations. Emma noted that the proposed strategy outlines key issues, risks, and next steps. An evaluation framework will measure improvements in transfusion safety. The General Medical Council (GMC) is contributing to this work by addressing blood transfusion competencies within medical school curricula. Emma noted challenges with implementation of recommendation 7(d), particularly in respect of ensuring that learning was taken forward in respect of SHOT reports. She stressed the need for a “once for Scotland” approach to ensure consistent training across disciplines, accessible education for all involved in transfusion, and clear transparency on completed training. Emma noted that NES was also aligning its work with recommendation 4(b), to embed cultural change in education, and with recommendation 10, to ensure patient involvement.

Emma reported that the NHS England-led group addressing recommendations 3(a) and (b) and 7(d), has been disbanded due to funding constraints. To continue to take forward their work in the light of the lack of 4 nations work, Emma made clear that some funding would now be needed to enable progression to phase two of the strategy. In discussions, Nicola Steedman queried whether an evaluation framework and other elements of the work proposed was usual practice for such NES projects, and Emma confirmed it was. The Chair emphasised that given the extent of the resources already in the NHS and the very tight funding situation, a very strong business case would need to be received before any further funding could be allocated.

Action 5: NES to provide a business case to the Secretariat setting out the level of further funding required and what it would cover (Emma Watson, NES).

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

James How confirmed that the next meeting will focus on recommendation 4 (patient safety) and recommendation 6 (monitoring liver damage in individuals infected with Hepatitis C). He invited members to suggest any additional topics for inclusion and notify the Secretariat. James noted that, by the end of the next meeting, the OAG will have reviewed all recommendations on which SG is leading. The next meeting is planned for late February or early March, with dates to be confirmed by the Secretariat.

Any other business

There was no other business.

Summary of action points

Action 1: John Dearden to send examples of missing text, following which the Secretariat will review the workplan (John Dearden, HS, and Secretariat)

Action 2: SNBTS to continue to participate in the UK work and to report back to OAG as necessary (Lorna McLintock, SNBTS)

Action 3: 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 and Secretariat)

Action 4: SNBTS to provide an SNA to Secretariat to support the approach on hospital blood bank sustainability, whilst waiting for the SPB  to consider the paper (Lorna McLintock, SNBTS)

Action 5: NES to provide a business case to the Secretariat setting out the level of further funding required and what it would cover (Emma Watson, NES).