Classification: Official
Publication reference: PRN01368

To:

• All integrated care boards and NHS trusts:
  • chairs
  • chief executives
  • chief operating officers
  • medical directors
  • chief nurses
  • chief people officers
  • heads of primary care
  • directors of medical education
• Primary care networks:
  • clinical directors

cc.

• NHS England regions:
  • directors
  • chief nurses
  • medical directors
  • directors of primary care and community services
  • directors of commissioning
  • workforce leads
  • regional heads of nursing
  • regional heads of communications

Dear colleagues,

Publication of the infected blood inquiry final report

Earlier today, the Infected Blood Inquiry published its final report at: www.infectedbloodinquiry.org.uk/reports. The Prime Minister has subsequently issued an apology on behalf of successive Governments and the entire British state.

On behalf of the NHS in England, now and over previous decades, Amanda Pritchard issued a public apology, saying:

“Today’s report brings to an end a long fight for answers and understanding that those people who were infected and their families, should never have had to face.

“We owe it to all those affected by this scandal, and to the thorough work of the Inquiry team and those who have contributed, to take the necessary time now to fully understand the report’s conclusions and recommendations.

“However, what is already very clear is that tens of thousands of people put their trust in the care they got from the NHS over many years, and they were badly let down.

“I therefore offer my deepest and heartfelt apologies for the role the NHS played in the suffering and the loss of all those infected and affected.

“In particular, I want to say sorry not just for the actions which led to life-altering and life-limiting illness, but also for the failures to clearly communicate, investigate and mitigate risks to patients from transfusions and treatments; for a collective lack of openness and willingness to listen, that denied patients and families the answers and support they needed; and for the stigma that many experienced in the health service when they most needed support.

“I also want to recognise the pain that some of our staff will have experienced when it became clear that the blood products many of them used in good faith may have harmed people they cared for. 

“I know that the apologies I can offer now do not begin to do justice to the scale of personal tragedy set out in this report, but we are committed to demonstrating this in our actions as we respond to its recommendations.”

The report is sobering reading, documenting failings over multiple decades, and making recommendations across a wide range of areas, including recognition, support and compensation; education and training; monitoring of and testing for Hepatitis C; the safety of blood transfusions; preventing future harm, via duty of candour and regulation; as well as giving patients a voice.

We write now to set out the initial steps we are taking in response.

Support for those affected

The Department of Health and Social Care is providing £19 million over five years to provide a bespoke Infected Blood Psychological Support Service which is expected to be rolled out later this summer. 

We have listened to the experiences of those involved, including patients, their families and staff, and are working with them to design and develop this service, which will provide dedicated support for those affected, located around the country.

This service will include talking therapies, peer support, and psychosocial support, as well as access to other treatments or support for physical or mental health needs where appropriate. 

In the interim, the existing England Infected Blood Support Service remains available here: www.nhsbsa.nhs.uk/england-infected-blood-support-scheme.

Further information about existing testing and support services, including those commissioned by the Government, can be found at: www.nhs.uk/infected-blood-support.

Supporting affected staff

It is important to also recognise that some of our colleagues may be affected by the publication of today’s report in some way, whether through personal or professional connection to the issue.

Employers may therefore wish to increase promotion of their local health and wellbeing support for staff. Details of nationally-commissioned routes of support, including the 24/7 text helpline Shout and NHS Practitioner Health, can be found at NHS England – Support available for our NHS People.

Continuing to find and treat people with blood-borne viruses

Although it is likely that the majority of those who were directly affected have now been identified and started appropriate treatment given the time that has elapsed since the last use of infected blood products, there may be people who have not yet been identified, particularly where they are living with asymptomatic Hepatitis C.

We ask that systems continue to work with partners, including community groups and charities, as well as Hepatitis C Operational Delivery Networks, to promote local testing options for anyone at risk, or anyone who is concerned. This should include promotion of the new national service for at-home Hepatitis C self-testing kits, available via hepctest.nhs.uk. 

For those who are concerned about the risk of HIV infection, further information can be found here: information on HIV diagnosis and the HIV testing services search tool.

Hepatitis B, another infection that can be linked to infected blood, usually clears up on its own without treatment; however, people concerned about Hepatitis B infection should be directed towards relevant hepatitis B information or their local sexual health clinic or GP practice.

Today’s report highlights that in some cases those affected by infected blood products were told of their diagnosis in ways which were insensitive and inappropriate. We would therefore ask you to ensure that patients and their families are supported through the process of receiving test results – of whatever kind – in a compassionate and considerate way. 

Ensuring patients can access the right information

We recognise following the publication of this report, some patients may raise questions directly with their primary and/or secondary care teams, or through other points of contact with the NHS. We will be sharing materials with relevant service providers to ensure frontline clinicians and other colleagues in patient-facing roles are able to provide appropriate information or signposting.

We expect that this will be particularly relevant to:

• Providers of NHS 111 services
• GP practices and community pharmacies
• Trusts providing services where blood products are used
• Mental health providers

Maintaining confidence in current blood and blood products and related treatment

The infected blood and blood products that have been the subject of this Inquiry were withdrawn in 1991. In the intervening decades, comprehensive systems have been put in place to ensure the safety of both donors and recipients of blood and blood-derived products.

Today, blood and blood products are distributed to NHS hospitals by NHS Blood and Transplant (NHSBT), which was established in 2005 to provide a national blood and transplantation service to the NHS. NHSBT’s services follow strict guidelines and testing to protect both donors and patients. 

NHS Blood and Transplant has published clear information about these processes here: Infected Blood Inquiry – NHS Blood and Transplant.   

Nationally, NHS England will work with NHS Blood and Transplant and others to communicate the safety of current blood products.

Assessing further recommendations and next steps

As set out above, the final Inquiry report includes a number of important recommendations for the NHS. NHS England will be considering these in detail alongside the Department for Health and Social Care and other relevant bodies.

In addition, an Extraordinary Clinical Reference Group is being convened to inform any immediate actions which should be taken.

The next steps from this work will be shared as soon as possible, including through relevant clinical networks.

Yours sincerely,

Amanda Pritchard, NHS Chief Executive, NHS England.
Professor Sir Stephen Powis, National Medical Director, NHS England.
Dame Ruth May, Chief Nursing Officer, England.
Dr Emily Lawson DBE, Chief Operating Officer, NHS England.