Nothing can bring back the 3,000 or so people who died as a result of contaminated blood products given to them by the NHS from the 1970s to the early 1990s. Thousands of others continue to struggle with viruses acquired in the same way, while others live with the knowledge that loved ones, including children, died or were infected needlessly. The report of the infected blood inquiry, published on Monday, has been far too long in coming. Victims of this disgraceful episode were fobbed off for decades, before the then prime minister Theresa May agreed to a public inquiry in 2017.
That decision was taken under strong pressure from campaigners. Andy Evans, who was infected with hepatitis C and HIV as a child, has described the official response as “kicking and screaming” all the way. The statement by the inquiry’s chair, Sir Brian Langstaff, on Monday was greeted with a standing ovation. But campaigners’ relief is mingled with anger and sadness. Truth, justice and accountability should not have been delayed for so long.
As prime minister, Rishi Sunak had the job of offering the formal apology that victims deserved. In the House of Commons, he called it “a day of shame for the British state”. Given the timing, compensation is more likely to be paid out under Labour. But this scandal cannot be laid at the feet of one party, and involves civil servants as well as politicians. Sir Brian said the thwarting by officials of one minister’s proposal for financial support was reminiscent of Yes, Minister, and blamed Whitehall for a theme of “institutional defensiveness”.
He also criticised the lack of a “patient safety culture” in all four UK health services. (While Scotland is included in his report, a separate Scottish inquiry has already taken place.) Decisions to award licenses to commercial blood products from the US, based on pooled donations, were wrong, given what was known about the risks. Screening of blood for hepatitis C should have been introduced sooner. The haemophilia expert Prof Arthur Bloom gave flawed advice, minimising the risk of catching HIV from the factor VIII used to treat bleeding disorders.
Probably the most shocking single episode took place at Treloar’s, a special boarding school in Hampshire. There, boys with haemophilia were used as guinea pigs by doctors who prioritised research over their best interests, and failed to seek consent.
Such actions, along with repeated cover-ups, mean that the wider “disaster” should not be seen as accidental, Sir Brian said. Decisions about criminal prosecutions, which remain a possibility, lie outside his inquiry’s scope. But the report makes a series of recommendations, including the creation of a new statutory duty of candour for healthcare leaders and civil servants. Mindful of ministers’ patchy record in following through on previous public inquiries, Sir Brian told victims that he plans to stick around.
Andy Burnham, the former health secretary and Manchester mayor, has previously blamed the Treasury for past inaction. He said that the expected cost of up to £10bn was the reason, along with “reputational interests”. Neither of these motives is unique to the infected blood inquiry, and Sir Brian pointed to parallels with the miscarriages of justice linked to the Post Office’s flawed Horizon system.
But the length of time it has taken for those whose lives were devastated by infected blood to gain some measure of justice puts this scandal in a league of its own. It is gravely concerning that politicians, civil servants and doctors are all implicated not only in the original poor treatment of a vulnerable group of patients but also in a long fight to bury the truth.
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