Infected blood inquiry: implementing recommendation 7e, SHOT reports (WHC/2025/037)

Status:

Action.

Category:

Policy

Title:

Infected Blood Inquiry: Implementation of Recommendation 7e: Implementing SHOT reports

Date of expiry or review:

Non-applicable.

Action by:

• Chief executives.
• NHS Wales health boards and trusts.
• Medical directors.
• Primary care leads.

Required by:

Immediate.

Sender:

Dr James Calvert,
Deputy Chief Medical Officer,
National Clinical Director NHS Wales.

Welsh Government contacts:

Catherine Cody,
Quality and Safety,
Quality and Nursing Directorate.
Email: QualityAndNursing@gov.wales

Enclosures:

Joint letter from the Deputy Chief Medical Officer for Wales, and the Chair of the Blood Health National Oversight Group.

Dr James Calvert FRCP PhD MPH Deputy Chief Medical Officer National Clinical Director NHS Wales Dirprwy Brif Swyddog Meddygol Cyfarwyddwr Clinigol Cenedlaethol GIG Cymru

Dr. Brian Tehan MSc FRCAI MB BCh BaO Chair of the Blood Health National Oversight Group Cadeirydd Grŵp Goruchwylio Iechyd Gwaed Cenedlaethol

25 September 2025

Dear colleague,

RE: infected blood inquiry: implementation of recommendation 7e: implementing the serious hazards of transfusion (SHOT) reports

Following the publication of the Infected Blood Inquiry (IBI) Report and its recommendations on 20 May 2024, an oversight group has been tasked with monitoring their implementation. As chair, I am writing to you today regarding 'recommendation 7 patient safety: blood transfusions' and specifically recommendation 7e concerning implementing SHOT reports.

You can access the full report via the infected blood inquiry website.

Recommendation 7. Patient safety: blood transfusions

(e) That all NHS organisations across the UK have a mechanism in place for implementing recommendations of SHOT reports, which should be professionally mandated, and for monitoring such implementation.

SHOT is the UK's independent haemovigilance scheme aimed at improving patient safety in blood transfusion by monitoring and reporting adverse events. In response to reported challenges in implementing recommendations, recurrent reporting trends, and the need for greater organisational accountability, SHOT has launched the SHOT Transfusion Safety Standards ^{[Footnote 1]} which will replace recommendations as part of its annual report. These standards aim to support safe and effective transfusion practices by identifying risks and promoting strategies that enhance patient outcomes, staff wellbeing, and overall system safety. A baseline assessment tool has been developed to help organisations evaluate their compliance with these standards.

In Wales, the Blood Health National Oversight Group (BHNOG) plays an oversight role as part of its remit to ensure safe and appropriate transfusion. This activity has been facilitated by the BHNOG Transfusion Risk Group (TRG) (previously BHNOG SHOT Working Group). The TRG will continue to monitor and support the implementation of the transfusion-related safety standards, including coordinating gap analyses and benchmarking activities. Reporting and escalation will follow the established route through BHNOG to Welsh Government (WG).

The TRG have identified that the responsibility for compliance with SHOT recommendations often falls to the operational Hospital Transfusion Team (HTT) members with limited organisational support to understand baseline compliance or support delivery of recommendations within the clinical settings.

To strengthen governance and board level oversight of patient safety related to transfusion, compliance with SHOT standards and transfusion associated risks, these should be incorporated into health boards’ patient quality and safety governance reporting structures and work in collaboration with the Hospital Transfusion Committee (HTC).

To support this, I would be grateful if the following were actioned by health boards and NHS organisations:

• establish a governance framework ensuring integration of the Hospital Transfusion Committee (HTC) for board-level oversight of the review and implementation of SHOT safety standards
• appoint an executive director with designated responsibility for the delivery and oversight of SHOT safety standards within the organisation
• undertake a comprehensive analysis of the SHOT transfusion safety standards, utilising the baseline assessment tool; due to the broad nature of the recommendations, this must be performed by the responsible personnel across the clinical, laboratory and managerial domains to ensure accuracy and accountability
• ensure submission of initial findings and proposed actions from the baseline assessment to the BHNOG Transfusion Risk Group by 31 December 2025
• identify a responsible committee within your governance structure to oversee ongoing improvement and barriers to implementation (this could be the board level committee to whom the transfusion and blood safety group reports)
• regular compliance review should occur to ensure ongoing improvement and identify any barriers to implementation; outcomes and process measures that demonstrate improvements should be reported to the BHNOG Transfusion Risk Group on a six-monthly basis, and NHS Performance and Improvement as part of your regular reporting

Thank you for your continued commitment to improving transfusion safety and patient care.

I would be grateful if you could confirm the action you have taken by cc'ing the relevant messaging to the qualityandnursing@gov.wales by 28 November 2025.

Yours sincerely,

Dr James Calvert
Dr Brian Tehan

1. SHOT Transfusion Safety Standards 2025. Available from SHOT Transfusion Safety Standards (Accessed 29 August 2025).