Infected blood scandal inquiry: Key findings from damning final report

Jeff Moore/PA Wire

In a 2,500-page report, the terrible extent of a scandal that led to the deaths of thousands of people has been exposed.

The government and the NHS were guilty of a decades-long cover-up of actions which led to the infection of tens of thousands of people and the deaths of around 3,000, the Infected Blood Inquiry has found.

More than 30,000 people were given “life-shattering” infections of HIV and hepatitis via the blood products, most of which “could and should have been avoided”, the report released on Monday concluded.

The inquiry into the “shameful” scandal found the public was falsely reassured, children were treated unnecessarily, evidence was deliberately destroyed, and that a significant number of people remain undiagnosed after receiving blood transfusions in the 1970s, 1980s and 1990s.

Politicians, doctors and civil servants were accused of compounding the immeasurable suffering of patients and their loved ones such that “the truth has been hidden for decades”.

John Glen, the Cabinet Office minister dealing with the scandal on behalf of the government, has refused to rule out criminal proceedings, saying: “If there’s clear evidence and there is a pathway to that, then it’s obviously something the government will have to address. I can’t be sure, but we’ve got to give these people justice.”

A compensation package for victims worth more than £10 billion is expected to be announced by ministers, while Prime Minister Rishi Sunak is set to apologise on behalf of the government.

Victims and campaigners outside Central Hall in Westminster, London, after the publication of the Inquiry report (Jeff Moore/PA Wire)

Here are key Infected Blood Inquiry findings:

1. The UK blood services failed to ensure rigorous donor selection and screening of UK blood donors to exclude higher-risk donors. They continued to collect blood from prisons until 1984, even though the risks were well known.
2. For both HIV and hepatitis C, the testing of blood donated in the UK was not introduced as quickly as it could have been.
3. Transfusions were frequently given in situations where they were not clinically needed. Patients were not warned of the risks of transfusions, and proper records of transfusions were not kept.
4. Despite government commitments, the UK failed to achieve self-sufficiency in blood products.
5. Commercial factor products – the blood products imported to treat many people with bleeding disorders – were unsafe and should not have been licensed in the UK.
6. Doctors treated patients with increasing volumes of factor concentrates despite the known risks of viral transmission and without informing them of the risks. They gave false reassurance and failed to adjust patients’ treatment to make them safer.
7. It was apparent by mid-1982 that there was a risk that HIV, the cause of AIDS, could be transmitted by blood and blood products, but the government failed to take steps to address the risk. A 1983 decision not to suspend importation of commercial concentrates was wrong.
8. Research was conducted on patients with bleeding disorders, including children, without telling them, or their parents.
9. Patients were tested for both HIV and Hepatitis without their knowledge and sometimes without being informed of the results for weeks, months or even years, denying them the opportunity to control the progression of their illness or to prevent its spread to those close to them.
10. When patients were informed of their infection, it was too often handled in an insensitive and inappropriate way.
11. There were failures of support and palliative care for those dying due to their infections, and there were delays in accessing appropriate specialist treatment.
12. By contrast with HIV, no “lookback exercise” was carried out to find infected patients when universal screening of donations for hepatitis C was introduced.
13. The harms done to people infected and affected were compounded by the response to the infections, including repeated and ongoing failures by governments and by the NHS to acknowledge that they should not have been infected, as well as a lack of any meaningful apology, redress or compensation.
14. Documents, including medical records, were deliberately destroyed and many others were lost.
15. The government repeatedly made inaccurate, misleading and defensive statements, including telling people they had received the best treatment available.
16. Government responses remain outstanding to many of the recommendations of the Compensation Framework Study by Sir Robert Francis KC and the inquiry’s second interim report.