UK’s infected blood scandal inquiry report issued

UK’s infected blood scandal inquiry report issued

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by Mick the Ram

A report that has been issued following a public inquiry into a long-term infected blood scandal in the UK, has essentially found that authorities exposed victims to unacceptable risks and systematically kept truths from patients.

More than 30,000 people were infected from contaminated blood treatments, with over 3,000 losing their lives as a result and more will follow.

The five-year-long inquiry discovered that safety had not been paramount in decision-making, despite knowing the danger that was apparent for transmitting viral infections in blood and blood products.

The findings accuse doctors, government and the NHS of letting patients catch HIV and hepatitis, as well as having to live under the shadow of further health problems, debilitating treatments and long-term stigmas.

Sir Brian Langstaff, who chaired the inquiry, said the scale of the scandal was “horrifying” and the “disaster was not an accident” with “catalogue of failures” and a “pervasive” cover-up by the NHS and successive governments.

Current prime minister, Rishi Sunak, said he is truly sorry for what he called a “decades-long moral failure”, describing it as a “day of shame for the British state”.

Biggest treatment disaster in history of NHS

The infected blood scandal is now accepted as the biggest treatment disaster in the history of the NHS. After an inquiry was ordered it looked at over 50 years of decision-making before, during and after the infection of thousands of people from contaminated blood transfusions and blood products, dating back into the 1970’s.

It uncovered shocking evidence that victims had been failed “not once but repeatedly” by doctors, the NHS, government and others responsible for their safety.

Shocking findings

Just some of the findings included: the failure of the licensing regime to recognise unsafe products; continuing to import blood products from high-risk donors from abroad, especially the US where prisoners and drug addicts had been paid to give blood; and taking until the end of 1985 to heat-treat blood products to eliminate HIV (Human Immunodeficiency Virus) despite the risks having been known since 1982.

Indeed, it was found that the government of the time ignored a warning in 1983 from one of the UK’s top infectious-disease experts, Dr Spence Galbraith, that all imported US blood products should be withdrawn from NHS use until the HIV risk had been “clarified”.

Accusation of “downright deception”

Sir Brian said the “life-shattering” scandal had destroyed “lives, dreams, friendships, families and finances”. He wrote that some of the people infected and affected have been able to tell powerful stories of pain, sickness and of lives damaged and destroyed, prompting him to call the government “cruel” for falsely telling people they had received the best medical care.

He noted that there had been a lack of accountability, deliberate concealment and elements of “downright deception”, which included the destroying of documents, which indicated knowledge of wrongdoing.

He called it an “institutional defensiveness” by the NHS, the civil service and successive governments, as well as pointing out that doctors had then compounded the harms done. The truth he said, had been hidden, with people not told what they had every right to know. That was from initial risks of treatment, right the way up to not even being told they were actually infected.

He highlighted that the bottom line was “the infections happened because those in authority – doctors, the blood services and successive governments – did not put patient safety first.”

Children suffered unnecessary risk and pain

Sir Brian also reported that around 380 children with bleeding disorders, had caught HIV after being given blood products for their condition and many had died in childhood or young adulthood, having endured a level of pain and fear no child or young person should ever have to face.

There was circumstantial evidence against the Alder Hey Children’s Hospital in Liverpool, which specialised in treating children with bleeding disorders from the late 1970’s onwards.

Doctors there used Factor 8 concentrate containing contaminated blood to treat the youngsters, even after other haemophilia centres stopped using them on children. Alder Hey’s director from that time, Dr John Martin, “did not regard the risk of Hepatitis as a reason to alter any treatment regime” thus exposing the young patients to “wholly unnecessary risks”.

Specialist professor failed to link infections to blood products

The report mentions several individuals who it was felt contributed significantly to the situation that unfolded.

Professor Arthur Bloom was considered one the UK’s leading haematologists in the 1970’s and 80’s, and according to the report it was his opinions which “overly influenced” the way the governments of those decades viewed the emergence of Aids (acquired immune deficiency syndrome) and played down the threat to people with bleeding disorders, especially his advice to continue importing commercial factor concentrates.

Sir Brian said the professor, who died in 1992, “must bear some of the responsibility for the UK’s slowness in responding to the risks of AIDs to people with haemophilia”, because he is quoted as saying he was “unaware of any proof linking infections to the blood products” so was happy that there was no need to change patients’ treatment.

Current lord comes under fire

Also amongst the specific individuals criticised was Kenneth Clarke, now a lord, who was a health minister in Margaret Thatcher’s government from 1982 to 1985, then health secretary from 1988 to 1990.

He was accused of being “somewhat blasé” when he gave evidence to the inquiry about the collection of blood from prisoners as late as 1983. His manner was described as “argumentative, dismissive and disparaging” towards those who have suffered.

There were immediate calls for his peerage to be removed.

Thatcher government heavily criticised

Mrs Thatcher herself did not escape the criticism, along with subsequent governments and health secretaries. They all continually said infections were “inadvertent” and insisted that patients were being given “the best treatment available on the then current medical advice”.

The inquiry report concluded that simply was not true and said the factual basis for those people to repeatedly make that claim, was unclear. The Thatcher government in particular “did not respond appropriately, urgently and proactively” to the risks of Hepatitis C and HIV transmissions through blood.

PM offers “unequivocal” apology

The report made stark reading for politicians of the present day, none more so than PM, Rishi Sunak. He offered a “wholehearted and unequivocal” apology to all those affected, accepting that the report highlighted a “decades long moral failure at the heart of our national life.” 

He said the attitude of denial was hard to comprehend and was to “our eternal shame” and the findings should “shake our nation to its core”.

Labour leader Sir Keir Starmer apologised too on behalf of his party and previous labour governments. He described it as one of the “gravest injustices” the country had seen, acknowledging that the victims had “suffered unspeakably”.

NHS in the firing line

The report expressed a belief that there had been a “hiding of much of the truth” from the NHS in order to “save face and to save expense”. Indeed, it was discovered that in many cases, patients were knowingly exposed to unacceptable risks of infection, with transfusions frequently given when not clinically needed.

The chief executive of NHS England, Amanda Pritchard, issued an apology on behalf of the health service, saying that tens of thousands of patients were “badly let down”, by failures to “clearly communicate, investigate and mitigate risks” to patients.

Compensation will be “whatever it costs”

With regards to compensation, Sir Brian’s two earlier reports, in July 2022 and April 2023, made certain recommendations which had led to the government making interim payouts of £100,000 each to about 4,000 survivors and bereaved partners.

However, on the release of the full report, Mr Sunak promised to pay “whatever it costs” to victims, with details expected to follow very soon.

It had been noted in the report that back in the time of Mrs Thatcher’s government they had “plainly formed the view, at an early stage, that nothing had been done wrong, and that no financial assistance would be provided to people with bleeding disorders who had been infected with HIV.”

It is a shame some of those individuals are no longer around to explain themselves and face up to their shocking decisions. It is very possible that criminal charges will be brought against some individuals and organisations, moving forward.