By Ben Kerrigan-
The Infected Blood Inquiry, led by Sir Brian Langstaff, has exposed widespread failures in the UK’s healthcare system that led to the infection of thousands of people with HIV and Hepatitis C through contaminated blood products.
The inquiry, which has taken several years to conclude, highlights a series of negligent practices and systemic issues within the National Health Service (NHS) and government bodies that have resulted in untold suffering and loss of life.
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Sir Brian Langstaff, the chairman of the Infected Blood Inquiry, said: “This disaster was not an accident. The infections happened because those in authority – doctors, the blood services, and successive governments did not put patients first. The response by those in authority served to compound people’s suffering.”
Sir Brian described a “catalogue of failures” in a report that runs to more than 2,500 pages and covers over five years of investigation. He said those failings amount to “a calamity” and were “systemic, collective and individual”.
The Department of Health adopted a narrative that nothing could have been done differently in the tragic infections of people with haemophilia.
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Ken Clarke, then the health minister in 1985, said the infections were “the unavoidable adverse effects which can unhappily arise from many medical procedures”.
Sir Brian accused the Government of “blindness” in parroting this line, “which was wrong from the very outset, then became entrenched for around 20 years: a dogma that became a mantra”.
Sir Brian urged the Government to pay compensation now, said that a memorial to the victims should be built at public expense and suggested that the NHS and Civil Service should undergo cultural change to fix “a culture of defensiveness”
Sir Brian Langstaff’s findings paint a stark picture of a healthcare crisis that was compounded by bureaucratic inefficiency and a lack of transparency.
Over 30,000 people were infected with HIV and hepatitis C from 1970 to 1991 by contaminated blood products and transfusions.
About 3,000 of them have since died – many haemophiliacs given infected blood products as part of their treatment.
The report criticizes the failure of clinicians to properly inform patients of the risks associated with blood and blood products, as well as the absence of adequate communication regarding alternative treatments. “These failures were widespread,” Langstaff stated, underscoring the systemic nature of the problem.
One of the most shocking revelations is the government’s continued collection of blood from high-risk populations, such as prisoners, despite knowing the heightened risk of hepatitis infections.
This practice was not halted until 1984, almost a decade after concerns were first raised by medical professionals.
“The chief medical officer for England in 1975 allowed the practice to continue, disregarding the elevated risks,” Langstaff noted.
Sir Brian Langstaff stressed the importance of patient consent to treatments and the failures of government in this matter
He was speaking after the publication of his infected blood report.
“The failure of clinicians to tell people of the risks of infection; the failure to tell people of the availability of alternative treatments.
“The failure to tell them they were being tested for HIV or Hepatitis C or, sometimes, the failure to even tell them or tell them promptly, that they had been infected with HIV or Hepatitis by their treatment.
“The failure to explain these devastating diagnosis privately, in person and with sensitivity.
“These failures were widespread, they were wrong, they were unethical.”
The failures were compounded by “institutional defensiveness” which “must stop”, he says.
The trauma for people with infected blood has been compounded by a lack of accountability.
The inquiry also highlights the slow and inadequate response of the government to the emerging HIV epidemic in the 1980s. Despite evidence of contaminated blood products spreading the virus, the government’s actions were characterized by “denials, disbelief, and delay,” according to Langstaff
Speaking following the publication of his report, inquiry chair Sir Brian Langstaff addresses what he expects from any government apology.
“I fully expect the government to make an apology. To be meaningful though, that apology must explain what the apology is for.
“It should recognise and acknowledge not just the suffering , but the fact that the suffering was the result of errors, wrongs done and delays incurred.
“It should provide vindication to those who have waited for that for so long.
“And it should be accompanied by action.”
The recommendations must be implemented, including setting up a proper compensation scheme, he says.
“The public should be trusted with the truth, with all its uncertainties.”
Lord Mayor Treloar College in Hampshire, was a specialist boarding school for children with physical disabilities, which had an onsite haemophilia centre.
A whole 122 pupils with haemophilia who attended the school from the 1970s to mid-80s, have died after contracting HIV and hepatitis C from infected blood products. Those still alive are plagued by survivor’s guilt, having lost so many friends.
Sir Brian described the experiences of children at Treloar’s as a “nightmare of tragic proportions”, adding that children were treated “unnecessarily” with more risky treatment and were objects of research without their knowledge.
The school has issued a statement on the inquiry’s findings:
It said: “The inquiry’s report shows the full extent of this horrifying national scandal.
“We are devastated that some of our former pupils were so tragically affected and hope that the findings provide some solace for them and their families.
“The report lays bare the systemic failure at the heart of the scandal.
“Whilst today is about understanding how and why people were given infected blood products in the 1970s and 80s, it is absolutely right that the government has committed to establishing a proper compensation scheme.
“This must happen urgently after such a long wait.
“On a recent visit to the school and college, our former students highlighted the need for a more public and accessible memorial to ensure the lives of all those impacted are remembered.
“This is a key recommendation of the report and something which we are absolutely committed to exploring with them.
“We’ll now be taking the time to reflect on the report’s wider recommendations.”
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