Professor John David Cash was a specialist in transfusion medicine who made important contributions to his specialty in Scotland, becoming the national medical and scientific director of the Scottish National Blood Transfusion Service (SNBTS). His influence in blood transfusion extended well beyond Scotland, and it was recognised when he became the President of the British Blood Transfusion Society (1997–1999). Born in 1936 in Reading, Berkshire, he was educated at Ashville College, Harrogate, where he was the dux of his year, and then at the University of Edinburgh where he qualified with a BSc (Hons) in 1959, an MBChB in 1961 and a PhD in 1967. In recognition of his contributions to transfusion medicine, he was appointed to an honorary chair at the University of Edinburgh in 1986.
Figure 1 Professor John Cash. Painting by Keith Breeden (b.1956)
John held pre-registration residence posts in the Royal Infirmary of Edinburgh in medicine (Sir Derrick Dunlop) and in surgery (Sir Michael Woodruff), and then went on to gain further clinical experience in general medicine. Thereafter, he studied for six months in the USA on a WHO Travelling Scholarship before beginning work for a PhD with Dr Robert Cumming in the South East Scotland Blood Transfusion Centre. He chose to study fibrinolysis in healthy subjects, a continuation of work he had done as an undergraduate medical student, and showed that exercise caused the release of plasminogen activator and coagulation Factor VIII in healthy subjects. He then went on to show that desmopressin (DDAVP), an analogue of vasopressin, free of its severe vasoactive side-effects, stimulated Factor VIII release.1,2These discoveries allowed the subsequent development of DDAVP as a successful treatment for mild haemophilia and for von Willebrand disease.2 Thereafter, John’s attention turned to the advancement of transfusion medicine and the management of services for blood and blood products.
The UK blood services and recipients of blood and blood products owe an enormous debt to John Cash. He was never afraid to speak his mind, even if this would make him unpopular with the establishment. He was highly respected at home and abroad and inspirational to many. There are very few who have made a real difference in our UK blood services; John was certainly one of them.
From the early stages of his career, John kept abreast of advances in the fields of safe blood and blood products procurement and transfusion medicine. His global perspective was evident through his contact and friendship with colleagues worldwide. Although he developed a reputation for challenging the powers that be, colleagues who came to know him saw him as a thoughtful, compassionate professional who cared deeply about donors and patients. He was greatly admired by doctors in under-resourced countries, for whom he would always find time to give sound advice.
As Director of the SE Scotland Regional Transfusion Centre (1979–1988) and then Medical and Scientific Director of the SNBTS (1988–1998), John was passionate about self-sufficiency in blood and blood products and proud of the achievements of the SNBTS in this area. However, self-sufficiency in plasma products, especially Factor VIII, resulted in a surplus of red cells in some centres, with the consequent exportation to centres in England, unaware that neighbouring Scottish centres might be in need. In the 1980s, recognising the benefits of sharing blood stocks nationally, John established an IT system in which daily information on blood stocks in each SNBTS centre was available. The system enabled centres in need to obtain support from centres with a surplus.
In parallel with aiming at self-sufficiency from voluntary altruistic blood donors, essential for the safety of the blood supply, John was passionate about the duty of care to blood donors and would go a long way to defend their rights and their health. In the 1970s he correctly predicted that importing plasma products from abroad would lead to disastrous consequences.3 In 1984 he was critical of the tardiness and lack of interest of the Department of Health and Social Security (DHSS) in assessing and introducing anti-HIV screening kits. In fact, he was so outspoken on the subject that he was asked to resign from the Expert Advisory Group on AIDS. Although anxious to introduce anti-HIV screening of blood donations as soon as possible, as a donor advocate he was preoccupied with the selection of appropriate tests and of confirmatory assays in reference laboratories, as well as the creation of alternative testing sites. This latter was to ensure that individuals who were non-donors but believed they were at risk of HIV infection would not take advantage of the anti-HIV screening of blood donations and come to give blood simply to ascertain their HIV status. He won part of this battle, as the SNBTS Microbiology Reference Centre was created in 1989, but alternative testing sites were not. John also played a pivotal role in bringing change to blood services south of the border. In 1997 he led an independent review of the English National Blood Service (NBS), mostly to deal with the advisability of transferring processing and testing of blood from Liverpool to Manchester, as part of the proposed NBS consolidation. With his characteristic energy and enthusiasm, John extended his remit and was not shy to recognise serious failures at the organisational and management level of the National Blood Authority (NBA), with under-resourced blood centres such as Liverpool, Cambridge and Oxford.
John later gave evidence to the Penrose Inquiry (2008–2015) into hepatitis C virus (HCV) and HIV infection from blood and blood products in Scotland and was critical of the final report. He was due to give evidence to the current UK Infected Blood Inquiry. In his characteristic charismatic and direct way, he would have been a key witness, with personal insight into the response of the Department of Health (DoH) to support self-sufficiency in plasma products and of the late introduction of screening tests for HIV and HCV.
His close colleague (MC) said ‘In the fields of the blood services and transfusion medicine, there are very few doctors with the temerity and conviction that John showed throughout his life. I consider him a giant amongst my peers and I feel proud to have been his friend.’
John’s interests in medicine were not confined to transfusion medicine. He became a Fellow of the Royal College of Physicians of Edinburgh in 1970, served as a member of the College Council from 1988, was elected Vice-President in 1992 and President from 1994 till 1997. John was the first non-clinician to be elected President since Second World War; this was a tribute to the high regard in which he was held, especially for his leadership, his energy, his impartiality and his great good sense. His College portrait, shown here, sums up his strong and warm personality. He became an active member of the College’s Senior Fellows’ Club and a convivial contributor to the twice-yearly past Presidents lunches held under strict Chatham House rules!
John was a sociable and natural leader with endless drive and enthusiasm. At school he captained the rugby team and he later became captain of Edinburgh University’s rugby team. His love of sport continued throughout his life.
He also loved tackling new projects, large or small. Whether it was the co-founding of and playing for the Edinburgh City Hospital cricket team, the creation of a new trout fishery near the Tweed, the design of gardens at home and abroad or the simple pleasure of masterminding the construction of a raft on a family holiday, his enthusiasm was infectious.
John’s love for the countryside was embodied in his cottage in the Borders where he transformed rough terrain into attractive woodland. Typically he established warm friendships with his neighbours, competed in the local flower and vegetable shows and espoused local causes, about which he wrote pithy and sometimes provocative articles in the local press under the nom de plume ‘Badger’. For a few years he enjoyed game shooting where his main pleasures were the company of his friends and working with his beloved dogs.
In the 1970s John’s interest turned to fly fishing and, with three friends, he began what they termed their annual ‘piscicidal congress’ – though this was a slight misnomer since most fish were returned to the water unharmed. For the next 30 years they enjoyed wonderful lakes and rivers in almost every corner of the UK and Ireland.
As ill-health developed, John limited his fishing to Lough Corrib in the West of Ireland. The attraction of these parts was not just the fine fishing in beautiful loughs but, above all, the warmth of the hospitality and the Irish ‘craic’. When his favourite ghillie sought advice on landscaping the large garden of his newly built house John personally selected and planted every single tree. Latterly, although he no longer had the strength to cast a fly, he still insisted on travelling west to revisit his friends and watch his trees flourish.
Throughout his working life and retirement John’s pride and joy lay in his family; his wife Angela, his son Mike, his daughter Julie and his five grandchildren. He was in constant touch with each grandchild, nourishing and supporting their academic, sporting and musical achievements. To follow their progress, he once remarked, was his main reason for living. 
References
1 Cash JD, Garder AMA, Da Costa J. The release of plasminogen activator and factor VIII by LVP, AVP, DDAVP, ATIII and OT in man. Br J Haematol 1974; 27: 363–364.
2 Cash JD. DDAVP and factor VIII: a tale from Edinburgh. J Thromb Haemost 2003; 1: 619–621.
3 Cash JD, Spencely M. Haemophilia A and the blood transfusion service: a Scottish study. Br Med J 1976; 2: 682–684.
