Infected Blood Inquiry Hearing – 9th November 2021

Today’s hearing was the first of a series in the coming months that will focus more specifically on issues around blood transfusions.

Katie Scott (Junior Counsel) set out a thorough history of blood donations and how they were managed from 1921 onwards, when the first Blood Donation Panel was formed.

Back then transfusions were directly from person to person and donors were all volunteers who would be called to the hospital when needed.  Provisions were made to keep them away from the main wards, so as to avoid coming them into contact with any people who were sick, so they could be in a more sterile environment and they were also supported psychologically.

By 1939, blood depots were created, as there was a breakthrough in the ability to store blood, by being able to stop it coagulating using sodium citrate.  Regional centres were created across the UK to supply hospitals and by 1946 the National Blood Transfusion Service for England and Wales was created comprising of 12 regional and 2 London centres.

By the time the NHS was formed in 1948, management devolved to the regions from the government.  The regional transfusion centres were responsible for collecting, testing, delivering and also promoting the need for a supply of blood (and blood products, e.g. the removing of plasma or making of cryoprecipitate) in their respective areas. 

As the regional transfusion centres were autonomous, some developed slightly different ways of operating.  By the 1970s, with the formation of Area Health Boards in the NHS, sometimes with several, within a “region”), it was soon agreed that central funding and management would be the best way forward, despite regional transfusion centres wanting to remain as they were. 

By 1972 it was felt that central coordination was absolutely essential and by 1974 with the change from Regional Health Boards to Regional Health Authorities, there was yet deeper departmental scrutiny.

A BMJ article in 1974 reported on the fact that self-sufficiency in the blood supply was not being met however, though the evidence suggested there was no actual shortage of donors, rather that there was insufficient staff, no effective planning, no resources or adequate numbers of centres to deal with it.

It said "Finally, there is no evidence to support the conclusion that the failure of the Blood Transfusion Service to meet the increasing demands rests at the feet of the voluntary blood donor. Indeed the evidence suggests that there is no shortage of voluntary donors in Britain prepared to come forward and contribute to local and national needs. The problem rests on the quality of management (or lack of it) which has led to a steady decline in the British Blood Transfusion Service since the late 1950s. There has been no effective national planning; the regional and protein fractionation centres now lack sufficient staff, accommodation, equipment and the basic organisational units to do the job.

Moreover, the medical staff in the centres are often geographically and administratively isolated from the care of patients. The remedy, then, is not for a topping-up exercise with donors offered theatre tickets or nylon stockings but for an urgent appraisal (for the first time) of a national policy for the procurement and eventual distribution of a natural resource which, unlike oil, will be still readily available in 100 years' time."

Ms Scott referenced another British Medical Journal "The blood transfusion service and the National Health", written by John Cash, National Medical Director of the Scottish National Blood Transfusion Service.

"The sustained failure of the transfusion services in England and Wales, known as the National Blood Transfusion Service, over the past two decades to meet the needs of the National Health Service extends far beyond the provision of factor VIII concentrates.

In London and the home counties there are chronic and occasionally serious shortages of blood, which have an appreciable impact on both the NHS and a large uncontrolled private sector… many general managers of regional health authorities must view their regional blood transfusion centres with some concern. These centres continue to produce the therapeutic products against no nationally agreed specifications, yet are within nine months of new legislation on product liability. They are aware of severe shortages in adjacent regions but have no mechanism to give or receive help…

The National Blood Transfusion Service is a fragmented and disorganised shambles. Thus it has been possible, and on many occasions, for severe shortages of blood to arise in one part of the country while less than 10 miles away (in another region) the regional health authority is dismantling part of its blood collection programme because of sustained excesses… Somehow the concept of the 'gift relationship' of the voluntary donor and the needs of the patient have been lost by a service which in truth is a series of tight compartments with little or no facility to work together.  This system of management is wholly inappropriate for modern blood transfusion practice; it is both wasteful and dangerous…" which as we have unfortunately all learnt from previous hearings was extremely prescient.

Look Back Exercise

Sarah Fraser Butlin (Junior Counsel) spent the afternoon session reporting on the history of look back processes.  “Targeted lookbacks” were about the donor being identified and then any recipients being traced and “reverse lookback” was when a recipient was identified and the donor traced from there.

Although there was not a precise start date, reports of people getting “post transfusion jaundice” started to be recorded back as far as 1948 and it soon became clear that a reporting system needed to be established to monitor this.  The primary disease, reason for transfusion, onset of post transfusion symptoms and the amount of blood given was captured, though at that time batch numbers were not recorded.

It was reported by doctors that donors are “apt to be touchy” when questioned, which implied it had happened many times before.  Examples were given of a donors that simply did not respond to requests for information, denied having jaundice, were not registered with a GP, or who had moved with no forwarding address and could not be traced. 

Where blood bottles were later recorded, those that had dried plasma (which could be reconstituted for anything from 2 – 5 years afterwards), were also problematic to follow up on.

And by the 1960s there were reports coming in of the considerable resource implications of tracking down donors and the workload involved was becoming onerous for hospital staff to do.  An example was given by one doctor:

"It is worth considering what is involved in a hypothetical case which has had, for example, 7 bottles of blood and 3 of SP Dried Plasma (of different batches). Suppose the donors of the 7 bottles of blood have, between them, donated on 30 occasions. The fate of each donation has to be accounted for… that may mean going back 10 years, or more, in some donors. 

For each donation transfused, the recipients must be contacted.  We have to ascertain via the hospital, then GP, whether patient still survives. If alive, we must ascertain from the patient whether he, or she, had jaundice in the six months following transfusion; several cases have come to light in this way. In the case of donations used for plasma, the fate of the plasma must be ascertained and recipients traced, as above.

Finally, in case of SP plasma, all the donors contributing to the pools must be accounted for and all donations they have given back-traced as above… If this work is worthwhile, particularly as the machinery for a continuing survey in one region, we must have more hands for the job. As things are, this work must be cut down rather than increased."

Another described how the “burden of administration was a great discouragement to doctors in joining the NHS”.

Post transfusion jaundice was soon linked with hepatitis B and a case was described of a person receiving plasma on different occasions from 32 separate donors, 28 of whom were followed up and found to be negative - but the remaining 4 couldn’t be located…  It sometimes took several years to complete an investigation.

Even in 1996, despite many hospitals switching to computer systems, some still relied on paper records, requiring staff to go through files manually.

To read the full transcript of these hearings please see here

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