'Catalogue of failures, calamity, cover-up' - Infected Blood Inquiry report finally published
The long-awaited Infected Blood Inquiry has published its findings, seven years after being set up
Last updated 20th May 2024
The infected blood scandal "could largely have been avoided" and there was a "pervasive" cover-up to hide the truth, an inquiry into the biggest treatment disaster in the NHS has concluded.
Deliberate attempts were made to conceal the disaster, including evidence of Whitehall officials destroying documents, the Infected Blood Inquiry found, while patients were knowingly exposed to unacceptable risks of infection, the probe found.
The 2,527-page report documents a "catalogue of failures" which had "catastrophic" consequences, not only among people infected with contaminated blood and blood products, but also their loved ones.
Chair Sir Brian Langstaff stated "This disaster was not an accident".
Findings of the Infected Blood Inquiry
The report found:
- Patients were knowingly exposed to unacceptable risks of infection
- Doctors, blood services and successive governments did not put patient safety first
- Health departments did not issue guidance to curb unsafe use of blood products
- Patients were not informed of the risks of their treatment
- They were tested without consent, and not informed of the results. Some were later used in medical trials without their consent.
- When patients were informed of their infection, this was too often handled in an insensitive and inappropriate way.
The report also recommends that compensation is now paid to the victims of the blood scandal.
Report finds blood scandal 'was not an accident'
Chair of the Infect Blood Inquiry Sir Brian Langstaff said: “In families across the UK, people were treated by the NHS and over 30,000 were given infections which were life shattering. 3,000 people have already died and that number is climbing week by week.
"Lives, dreams, friendships, families, finances were destroyed.
"This disaster was not an accident. The infections happened because those in authority – doctors, the blood services and successive governments – did not put patient safety first. The response of those in authority served to compound people’s suffering.
"The government is right to accept that compensation must be paid. Now is the time for national recognition of this disaster and for proper compensation to all who have been wronged.”
Why was the blood inquiry set up?
Tens of thousands of people in the UK were infected with deadly viruses after they were given contaminated blood and blood products between the 1970s and early 1990s.
These include people who needed blood transfusions for accidents, in surgery or during childbirth, and patients with certain blood disorders who were treated with donated blood plasma products or blood transfusions.
Some 3,000 people have died and others have been left with lifelong health complications after being infected with viruses including hepatitis C and HIV.
It has been estimated that one person dies as a result of infected blood every four days.
The inquiry was first announced by former prime minister Theresa May in 2017, with the first official hearing held on April 20 2019.
It is one of the largest UK public inquiries.
Some 374 people have given oral evidence, and the inquiry has received more than 5,000 witness statements and reviewed more than 100,000 documents.
The search for justice
Many of those infected and affected by this disaster, in addition to dealing with the consequences of the original infection, have been forced into a decades long battle for the truth.
Successive governments claimed that patients had received the best medical treatment available at the time, and that blood screening had been introduced at the earliest opportunity.
The report finds both claims were untrue.
Whether it was young children, new mothers, or patients undergoing surgery, people were given treatments which shortened or ended their lives.
In thousands of families across the UK, someone was infected with Hepatitis or HIV, and the physical and psychological pain, stigma and grief are still being felt today.
People who survived have been "robbed of years of healthy life" with the lives of those around them - partners, family, children - fundamentally changed.
In-depth findings from the Infected Blood Inquiry
Here's more of the findings from the Inquiry - as set out by its Chair Sir Brian Langstaff
- The UK blood services failed to ensure sufficiently rigorous donor selection and screening of UK blood donors so as to exclude higher risk donors. They continued to collect blood from prisons until 1984 though the risks were well-known.
- For both HIV and Hepatitis C, the testing of blood donated in the UK was not introduced as quickly as it could have been, and surrogate screening methods, which could have been used before those tests were available, were not adopted.
- Transfusions were frequently given in situations where they were not clinically needed, and alternatives to transfusion were not used. Patients were not warned of the risks of transfusions, and records of transfusions were not kept when they should have been.
- It was apparent by mid-1982 that there was a risk that the cause of AIDS could be transmitted by blood and blood products, but the government failed to take steps to address that risk.
Successive governments fail to respond appropriately to the Blood Scandal
Also contained within the report are a series of failings from authorities - which it says compounded the harms already done to people through infecting them with contaminated blood, including:
- Repeated and ongoing failures by governments and by the NHS to acknowledge that they should not have been infected.
- The absence of any meaningful apology and redress.
- The repeated use by government of inaccurate, misleading and defensive lines to take, which included cruelly telling people that they had received the best treatment available.
- The deliberate destruction of some documents and the loss of many others.
- Failures of palliative care for those dying due to their infection with HIV or Hepatitis C.
- A refusal for decades to provide compensation.
The current government has also been criticised for failing to respond to the recommendations of the Compensation Framework Study by Sir Robert Francis KC during the inquiry's second interim report