24 January 2023: Closing Statements, Charlie Cory-Wright (NHS Blood and Transplant) - B

The present position (“how things have changed” for blood services) was the next sub-topic coming from NHSBT. There was a brief overview of organisational development moving towards a national structure; and even an international context. Several specialist bodies have been established covering issues of safety, production, and more. It was noted how the relationship over how these developments were rolled out when it came to Wales was somewhat complex.

 

There was a focus on “how decision-making happened”. This linked to the now internationally agreed standards. Reference was made to, for example, Canadian processes. These matters covered the key thread of risk management. There was also an emphasis on “stakeholder engagement” which was noted to have been lacking previously. The concept of risk assessment was standardised into an established five-by-five matrix or framework. Mr Cory-Wright also described the link between the specialist bodies who give advice and Ministers who make decisions.

 

The area of “haemovigilance” was the second consideration in relation to how they got to the present position. This topic was strongly linked to the two key bodies “SHOT” and “MHRA” and highlighted the liaison and joint reporting schemes involving them. Statistics on safety were presented as they relate to blood, showing it as a safe product currently. In the last year there were zero reports of “transfusion transmitted infections” (TTIs). The displayed documents included reference to a duty of candour. The “JPAC” group was also referenced as the body with responsibility to monitor infectious agents, and was connected to “SACTTI” (another long named but helpfully acronymed group). A proliferation of acronyms, along with a sackful of jargonistic management-speak ensured the subdued audience response throughout this stodgy section.

 

Mr Cory-Wright moved to highlight suggested recommendations from NHSBT for the Chair to consider. The first was about “risk-based decision-making” and sounded sufficiently technocratic to be worthy since it was based on lengthy framework documents which had been agreed with informed partners across the world. The matter of “The Precautionary Principle” was re-emphasised (about time too). At one point Mr Cory-Wright referred to what he was describing as “a systematic slightly mechanistic approach”; precisely. The interaction between an approach being “precautionary” and/or “proportionality” applied, was suitably dense to be passed over. This writer would suggest how good it is to know that there is (or should be) someone who makes sense of all this so the rest of us can rest safe in the knowledge there is a smart person looking out for our essential but perhaps impenetrable safety needs so we don’t have to.

 

Consent to transfusion was the next topic covered by a recommendation. “NICE” and “SaBTO” floated up as the latest lettered shorthands with a role to perform. In 2021 it was reported that 64% of patients had evidence of receiving written or oral information about risks. Next was “SHOT” (Serious Hazards of Reporting) which at least has a nifty acronym compared to others.

 

A series of related recommendation suggestions were derived from a document already supported by NHSBT, being a five-year strategy, the “Transfusion 2024 Plan”. It appear as if this organisational core participant wants it to be recommended by the Inquiry that it should follow a plan it has already endorsed and is already enacting. It also makes reference to funding and other resource needs to deliver the plan, so perhaps Sir Brian is being asked to produce a report which also fills the purpose of being a letter of support for them getting more funding. Maybe that is what is needed.

 

Recommendations also cover the issues of accountability and responsibility, including giving bodies such as NHSBT greater powers. Maybe that too is what is needed.

 

The final recommendation to be covered in the closing statement is concerning liver transplantation. The NHSBT wants principles and protocols to be strengthened, that is, to endorse their current preferred approach. The current approach of transplantation decisions is questioned by NHSBT, so they are seeking the Chair to stand in their corner on those matters they have obviously not yet convinced the key decision-makers of.

 

Additionally (as opposed to finally) there was a description of a preferable system for record keeping, the exclusion of risky donors such as people in prisons, and the evergreen topic of self-sufficiency. The closing statement of the UK Thalassaemia Society was praised and endorsed by Mr Cory-Wright. He quoted Ms Maharaj in relation to the experience of receiving blood.

 

A specific point was raised that the Welsh blood services body was fully supportive of the position being asserted by NHSBT.

 

Concluding remarks were made by Mr Cory-Wright. He did not want to challenge the evidence of, or to not respect, the experiences of infected and affected people. The factors of resource starvation and lack of coordinated control were pressed as mitigating factors, while not seeking to excuse what some people previously involved with the former blood services might have done. In the context of the challenges faced, there was acknowledgement of the work of current and former staff who had contributed to the health and wellbeing of so many patients for so long through their work within the blood services.

 

Mr Cory-Wright concluded by acknowledging each individual tragedy and recognised the negatively impactful part played by the blood services to which he reinforced how the NHSBT was deeply and truly sorry.

 

The Chair asked a question for clarification arising from two dates which are at odds between evidence sources. Mr Cory-Wright said it involved the NHSBT not recognising a particular potential fault of their or their predecessor bodies. There appeared to be a difference between expressions and significance of a relevant date. It required Mr Cory-Wright to quickly refer to his clients sitting immediately behind him, to confirm a point with them, then with the Chair, then to have nothing else to say.