Infected Blood Inquiry finds multiple failures

Written by Jessica Bomford, May 20, 2024

The Infected Blood Inquiry’s final report vindicates the long-held beliefs of survivors of the contaminated blood scandal that the government hid the truth to protect itself and to save money.

Today’s report is the result of six years of investigations and comes more than 40 years after this scandal began.

A hiding of the truth

Sir Brian Langstaff, Chair of the inquiry, concludes that many of the HIV and hepatitis C infections inflicted on our community could and should have been prevented. He said there had been a cover up which was ‘subtle…pervasive and…chilling’. He explained: ‘To save face and to save expense, there has been a hiding of much of the truth.’

Ministers, civil servants, clinicians and NHS bodies all failed to make safety the priority of their decision making and their action, the report finds.

Sir Brian said: ‘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.’

Prime Minister apologies

Later, Prime Minister Rishi Sunak apologised in the House of Commons on what he said was ‘a day of shame for the British state.’

Kate Burt, Chief Executive of the Haemophilia Society, said: ‘The Infected Blood Inquiry has found that the state and NHS bodies failed to protect peoples’ lives. A generation of people with haemophilia and other bleeding disorders were decimated by the infections they received through contaminated  blood products. Patients were treated without their consent; that was unethical and wrong.

‘A new institutional mindset must emerge as a result of the Infected Blood Inquiry’s investigations. People in need of support and care must be treated with dignity and respect. Those in power must listen to those they serve. Doctors must listen to their patients. Never again can the state turn its back on a humanitarian crisis which it helped to create.’

Summary of main findings

The report is extremely detailed, and there is still a lot to read. It states that infections, leading to deaths, illness and suffering were caused needlessly and many infections could have been prevented. The main conclusions are:

  • The licensing regime failed in allowing the importation of commercial blood products, such as factor VIII concentrates, which were known to be less safe than domestically produced products
  • The inept and fragmented blood services and a lack of investment in fractionation facilities failed to ensure sufficient supply of factor VIII could be produced from blood given by UK donors
  • The government allowed the increase in pool sizes for UK produced factor VIII and factor IX which increased the risks of viral transmission while failing to encourage and finance research into methods of viral inactivation
  • Viral inactivation and much greater self-sufficiency could have been achieved in the early 80s which would have led to far fewer hepatitis C infections and could have produced products free of HIV
  • Clinicians failed to make changes to treatment regimes to move to safer treatment, children were treated with riskier commercial concentrates and used as objects for research
  • In blood collections there were failures to implement donor selection and screening and delays in introductions of testing
  • Clinicians and the health service were complacent about the risk of hepatitis C and were too slow to respond to the risk of AIDS. They failed to tell people about the risks of treatments and offer safer alternatives
  • There were delays in diagnosis and treatment, in many cases of years, which risked the health of individuals and allowed the spread of infections to partners and other family members.

The Haemophilia Society

The inquiry has also made criticisms of the past actions of the Haemophilia Society. Although Sir Brian acknowledged that our charity acted with good intentions, he concluded that it was too slow to react to the risks of AIDS, placed too much reliance on the advice of haemophilia clinician Professor Arthur Bloom and failed to encourage members to decrease their use of factor concentrate. Sir Brian also found that the Haemophilia Society downplayed the significance of hepatitis C in the early 1990s.

We accept the inquiry’s findings in full. We have already apologised to our members for our actions in the past and do so again today.

Clive Smith, Chair of the Haemophilia Society, said: ‘We are very sorry for the hurt and anger which resulted from our advice and the breakdown of trust that followed. We cannot undo the decisions of the past, but we hope our actions throughout the inquiry and going forward demonstrate our determination to understand and learn from what happened.’

The report recommended that the Haemophilia Society should receive funding to enable us to continue our advocacy work.

Summary of report’s recommendations

The detailed recommendations of the report include:

  • A compensation scheme should be set up now in line with the recommendations in the inquiry’s report on compensation and redress published last year
  • Permanent memorials should be established to recognise and remember what happened
  • The lessons to be learned should be incorporated into every doctor’s training
  • There should be statutory duties of candour in healthcare, which should be reviewed, strengthened, and extended to people in leadership positions in the health service
  • There must be a cultural change in the NHS to deal with a lack of openness, failure to be forthcoming and a dismissiveness of concerns for patient safety
  • The four health systems in the UK need to improve patient records through digitisation, patient access, interoperability and timey and accurate update and review
  • The current non-statutory ministerial and civil service codes are not sufficient and must be strengthened
  • People who were infected with hepatitis C should have access to lifetime monitoring and the best available care
  • Blood transfusions should be better regulated, monitored, and recorded with greater use of tranexamic acid where possible to avoid the need for blood transfusions
  • Patients who have had blood transfusions before 1996 should be offered hepatitis C tests and patients should be routinely asked if they have had a blood transfusion
  • Haemophilia care should be routinely peer-reviewed, the findings of those reviews should be required to be acted on by trusts and more funding should be provided to the National Haemophilia Database
  • Recombinant coagulation products should be offered in place of plasma-derived products where clinically appropriate
  • Patient voice must be improved through routine collection of patient satisfaction data and funding for patient advocacy groups and charities.
  • In addition to existing powers under the Inquiries Act 2005 for ministers to announce public inquiries, there should also be a mechanism for parliament to refer the need for a public inquiry to the Public Administration and Constitutional Affairs Committee
  • Government to respond in detail to the recommendations either to accept that they will be recommended or explain in detail why they cannot this year
  • Progress towards implementing the recommendations should be reviewed by the Public Administration and Constitutional Affairs Committee.

We are expecting an statement tomorrow, 21 May, about compensation in the House of Commons at 12.30pm which will be repeated in the Lords.

Please bear with us as we work through this report, which contains a huge amount of information. Email any queries to [email protected]