The infected blood scandal was “not an accident” – and its failures lie with “successive governments, the NHS, and blood services”, a public inquiry has found.
From the 1970s, 30,000 people were “knowingly” infected with either HIV or Hepatitis C because “those in authority did not put patient safety first”, the inquiry’s report said. Around 3,000 people died.
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‘Downright deception’ – latest on long-awaited report
The response of the government and NHS has “compounded” victims’ suffering, said inquiry chair Sir Brian Langstaff.
This included the “deliberate destruction of some documents” by Department of Health workers, in what Sir Brian described as a “pervasive cover-up” and “downright deception”.
“It could largely, though not entirely, have been avoided. And I report that it should have been,” he added.
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NHS ‘betrayed’ victims – inquiry chair
Among key findings are:
- Patients were knowingly exposed to unacceptable risks of infection;
- The risk of blood products causing severe infection were well known before most patients were treated – in the case of hepatitis since the end of the Second World War;
- Transfusions were frequently given in situations where they were not clinically needed;
- Pupils at Treloar’s school were regarded as “objects of research rather than children”;
- Blood products imported to treat many people were unsafe and should not have been licensed for UK use;
- There was no contact tracing carried out when Hepatitis C screenings were introduced;
- There were repeated and ongoing failures by governments and the NHS to acknowledge people should not have been infected;
- They repeatedly used inaccurate, misleading and defensive lines;
- Infected people were “cruelly” told they received the best treatment available;
- There was a refusal for decades to provide compensation;
- Governments refused to set up a public inquiry until 2017
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Victims were ‘gas-lit for generations’
Sir Brian’s report makes 12 recommendations.
They include an immediate compensation scheme, memorials across the UK and at Treloar’s school, and that anyone who received a blood transfusion before 1996 be urgently tested for Hepatitis C.
New patients at any medical practice should also be asked if they had a transfusion before that time.
Prime Minister Rishi Sunak is expected to make an official apology on behalf of the government later today. The report stresses “it must be accompanied by action” for it to be meaningful.
Such action includes a “national recognition of this treatment disaster” and a change in culture across the NHS and civil service.
How the blood scandal happened
More than 30,000 people were infected with deadly viruses while they were receiving NHS care between the 1970s and 1990s.
The UK was not self-sufficient in blood donations in the early 1970s, so the government looked to the US for supplies to meet rising demand.
Batches of Factor VIII – an essential blood clotting protein which haemophiliacs do not produce naturally – started to be imported and used widely to treat the condition.
But much of it had been manufactured with blood collected from prisoners, drug addicts and other high-risk groups who were paid to give blood.
When the plasma was pooled together, it would take just one person carrying a virus to potentially infect an entire batch.
People were infected as donated blood was not tested for HIV until 1986 and hepatitis C until 1991.
The report mentions various politicians by name, including Ken Clarke, who was health secretary from 1988 to 1990.
It describes him as “unfairly dismissive” and “disparaging” towards victims, saying it would have “aggravated” their distress and upset.
Margaret Thatcher’s government claimed patients had “the best treatment available on the then-current medical advice” – but this was not true, the report says.
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The victms of the scandal
‘I lost my twin, cousins and two friends’
After the 2,527-page document was published, victims spoke at a news conference in central London.
Clive Smith, of the Haemophilia Society, said the “cover-up” came as “no surprise” to him and others affected.
“We’ve known for decades. Now the country knows, the whole world knows,” he said. “This was systemic, by government, the civil service, and healthcare professionals.”
Mr Smith added: “There are doctors out there who should have been prosecuted for gross negligence manslaughter… those people should have been in the dock.”
Nigel Hamilton, from Haemophilia Northern Ireland, described the devastating personal impact of the scandal.
“I lost my twin on Christmas Day. I lost two cousins in the last two years. I have lost two friends in the last two months,” he said.
“The production of this report has been both healing and supportive. Compensation is not an answer to the problems we have. But it will help.
“Successive governments are culpable of abandonment and neglect.”
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Jason Evans, from the Factor VIII campaign group, said: “Many of the politicians should hang their heads in shame… no single person has been responsible for this scandal.”
He added: “I would expect, over the coming days and weeks, for many more people to come forward and say sorry.”
And Andy Evans, representing the Tainted Blood campaigners, said victims had been “gaslit for generations”.
Challenging those in authority, he said: “We know that this should never have happened. What was your part in it?”
“Justice delayed really is – in this case – justice denied,” added Mr Evans.
Jackie Britton, from Bloodloss Families, said infected people were still struggling to get six-monthly scans and treatment.
“The government and the NHS should have a duty of care towards us,” she said.
“They have infected us, they have given us a death sentence.
