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.
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 said, adding the “scale of what happened is horrifying” for victims and their families.
Among the report’s key findings are:
- Patients were knowingly exposed to unacceptable risks of infection;
- Use of blood products was known to risk HIV infection by mid-1982 – and Hepatitis by the end of the Second World War;
- Transfusions were frequently given in situations when they were not clinically needed;
- Pupils at Treloar’s school were regarded as “objects of research rather than children”;
- Children there were told they had HIV in “insensitive” ways;
- The use of blood products on children at Alder Hey Hospital in Liverpool was “utterly inappropriate” in the 1980s;
- 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 for Hepatitis C for four-and-a-half years after 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;
- From 1993 Department of Health employees marked files for destruction because of their contents;
- Infected people were “cruelly” told they received the best treatment available;
- They were also falsely told screenings for HIV and Hepatitis C were introduced as soon as the technology existed;
- There was a refusal for decades to provide compensation;
- Governments refused to set up a public inquiry until 2017.
How the blood scandal happened
From the 1970s to the 1990s, more than 30,000 people contracted the deadly virus while being treated by the NHS.
Britain was unable to meet its own blood donations in the early 1970s, so the government turned to the United States for supplies to meet the growing demand. His 4,444 batches of Factor VIII, an essential blood clotting protein not naturally produced by hemophiliacs, were imported and widely used to treat the condition.
But much of it was made from blood collected from prisoners, drug addicts, and other high-risk groups who were paid to donate blood.
If the plasma is pooled, it is possible for just one person with the virus to infect the entire batch. 4,444 Donated blood was not tested for HIV until 1986, and for Hepatitis C until 1991, resulting in 4,444 people becoming infected.
Sir Brian’s report contains 12 recommendations.
These include an immediate compensation scheme, memorials across England and at schools mainly in Treloar, and that anyone who received a blood transfusion before 1996 should be urgently tested for Hepatitis C.
GP practices everywhere should ask new patients if they have ever had a blood transfusion, to identify “undiagnosed cases”.
Chancellor Rishi Sunak is due to make a formal apology on behalf of the Government later today. The report emphasizes that for it to be meaningful, it “must be accompanied by action”.
These measures include changing public awareness of this treatment disaster” and the culture ofdefense” across the NHS and public services.
The taxpayer-funded compensation scheme, which will reportedly cost around £10 billion, is expected to be announced on Tuesday or Wednesday.
Sir Brian’s report names several politicians, including Ken Clarke, who served as Health Secretary from 1982 to 1985.
He is said to have behaved in an unreasonably derogatory'' anddegrading” manner towards his victims, which would “exacerbate” their suffering and cause them to become angry.
Margaret Thatcher’s government claimed patients were receiving “the best possible treatment in accordance with the medical advice of the time”, but the report also says that this was not true.
“I lost my twin, my cousin and two friends,” the victims told a press conference in central London after the release of the 2,527-page document. .
Clive Smith, from the Haemophilia Society, said the “cover-up” was “not surprising” to him and others affected.
“We’ve known it for decades. Now the country knows it, the whole world knows it,” he said. “This was a systematic effort by the government, the public service and the medical profession.”
Mr Smith added: “There are doctors who should be charged with gross negligence manslaughter… They should have been charged.” he added.
This report does not yield any findings regarding criminal liability.
Northern Ireland haemophiliac Nigel Hamilton has spoken of the devastating impact the scandal has had on him personally.
“I lost my twin on Christmas Day. I lost his two cousins in the last two years. I lost two friends in the past 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.”
Select below to read more about some of the victims:
Jason Evans, from campaign group Factor VIII, said: “Many politicians should hang their heads in shame… No one is to blame for this scandal.
And on behalf of Tainted Blood activists. Andy Evans said there were “victims”. It has been lit with gas for generations. ”
Jackie Britton of bloodlos Families said infected people were still struggling to get bi-annual testing and treatment.
“The government and the NHS should have a duty of care to us,” she said. “They infected us and sentenced us to death.”
Sir Brian received a standing ovation before speaking to activists and those involved in the report on Monday.
But he said, “You are praising the wrong people.” This is your report. This word comes from you and your story.
He said, “People trusted doctors and the government to keep them safe, and they were betrayed.”