Royal Commission of Inquiry on the Blood System in Canada

Royal Commission of Inquiry on the Blood System in Canada

The Royal Commission of Inquiry on the Blood System in Canada, also known as the Krever Inquiry, was a landmark investigation into the Canadian blood system following a national public health crisis involving the contamination of the country's blood supply with HIV and Hepatitis C during the 1980s. Established in October 1993, the commission was led by Justice Horace Krever, and its findings have had a profound impact on the regulation and management of blood and blood products in Canada.

Background

During the late 1970s and 1980s, Canada experienced a significant public health crisis when thousands of Canadians were infected with HIV and Hepatitis C through contaminated blood and blood products. This crisis was exacerbated by the lack of effective screening and regulatory oversight, leading to widespread public outrage and demand for accountability and reform.

Mandate

The commission was tasked with investigating the causes of the contamination of the blood supply, the response of the blood system's management, and the regulatory failures that allowed the crisis to occur. Its mandate also included making recommendations to prevent such a tragedy from happening again.

Findings

The Krever Inquiry's final report, released in November 1997, was critical of the Canadian Red Cross Society (which was then responsible for the blood supply), the federal government, and other parties involved in the blood system. It highlighted a failure to prioritize the safety of the blood supply, inadequate regulatory oversight, and a lack of accountability among the organizations responsible for blood collection and distribution.

Recommendations

Justice Krever made 50 recommendations aimed at overhauling the Canadian blood system. Key recommendations included:

• The creation of a new, independent agency to oversee the blood supply, leading to the establishment of Canadian Blood Services and Héma-Québec.
• The implementation of a "vein-to-vein" system of regulation and surveillance, covering all aspects of blood donation and transfusion.
• The introduction of measures to ensure the safety and adequacy of blood and blood products.
• Compensation for those who had been infected through the blood supply.

Impact

The Krever Inquiry has had a lasting impact on the Canadian health care system and blood regulation policies worldwide. It led to significant reforms in how blood and blood products are collected, tested, and distributed in Canada, ensuring a safer blood supply and reducing the risk of similar crises in the future.

Legacy

The legacy of the Krever Inquiry includes not only the reforms it prompted but also a greater public awareness of the importance of blood safety. It has also influenced international policies on blood safety and regulation, contributing to global efforts to prevent the transmission of infectious diseases through blood transfusion.