The NHS and Government covered up the truth while documents were deliberately destroyed in the worst treatment disaster in the history of the health service, a landmark report has concluded.
In a horrifying report published today the Infected Blood Inquiry details a catalogue of failings at the heart of government and the health service. Over 30,000 people in the UK were infected with HIV and Hepatitis C after being given contaminated blood and blood products between the 1970s and early 1990s.
Spanning 2,572 pages and seven volumes, the Inquiry chairman Sir Brian Langstaff described the disaster as a "calamity" and made clear it was no accident. Deliberate attempts were also made to conceal the disaster, with some documents destroyed.
Sir Brian said the tragedy "could largely, though not entirely, have been avoided". Here The Mirror looks at the key failures highlighted by the report.
Contaminated blood scandal was not an 'accident'
Inquiry chairman Sir Brian Langstaff says the disaster "could largely, though not entirely, have been avoided". He said there was a failure to act over risks linked to contaminated blood - some of which were known before the NHS was established in 1948. Critically, he said there could have been fewer deaths if the UK had followed the World Health Organisation (WHO) from 1952. The organisation had identified how to reduce the risk of transmitting hepatitis through blood and blood products.
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Government and NHS covered up the truth
In a damning finding Sir Brian says there has been a "hiding of much of the truth". In the report, he says: "Not in the sense of a handful of people plotting in an orchestrated conspiracy to mislead, but in a way that was more subtle, more pervasive and more chilling in its implications. In this way there has been a hiding of much of the truth." Victims were also "cruelly" and repeatedly told that they had received the best treatment available.
Documents were stolen or deliberately destroyed
Three separate sets of documents were destroyed or lost, Sir Brian's report says. They related to the HIV litigation, minutes and papers from the Advisory Committee on the Virological Safety of Blood - ACVSB - and the Private Office papers of Lord David Owen, who was a health and social security minister between 1974 and 1976.
Sir Brian said that among the missing three sets of documents the ACVSB papers are the ones "known to have been deliberately destroyed". He added: "That is , a decision was made (by someone) that that was to happen, and it did. The destruction was not an accident, nor the result of flood, fire or vermin. The immediate reason for destruction was human choice. Someone, for some reason, had chosen to have those documents destroyed. The reason is not apparent. It is not self-evident."
Delays in informing patients about infections
In some cases victims were not told for months and even years they were infected. This denied them the chance to control their own illness and prevent the spread to loved ones. It adds that when some patients were informed of infection it was often handled in an insensitive way.
Children used as 'objects for research'
An entire chapter of the report focuses one chapter on pupils at a specialist school where boys were treated for hemophilia. It said of those who attended the Lord Mayor Treloar College in the 1970s and 80s, "very few escaped being infected". In harrowing detail it says of 122 hemophilia pupils, just 30 are still alive.
Sir Brian said it was "unconscionable" that children at the school were treated in a way that "trumped safety" without the risks being explained to their parents. He said: "The pupils were often regarded as objects for research rather than first and foremost as children whose treatment should be firmly focused on their individual best interests alone."
Failures in the licencing regime
The report states the import and distribution from 1973 of blood products - Factor 8 - from the US and Australia "which carried a high risk of causing hepatitis, and were understood to be less safe" than UK treatments. It said imports of commercially produced blood products should have been suspended in 1983 - but were not. There was also a failure to review this decision.
Increasing size of pools used to manufacture blood products in the UK
Increasing the size of pools used to manufacture blood products in the UK - despite the risk. The report says it was well known such a measure would increase the risk of viral transmission. This is because an infected donation could infect the whole pool.
The report adds UK blood services failed to ensure rigorous donor selection and screening. The report states services continued to collect blood from prisons until 1984 - despite the risks being well-known. It also states the testing of blood for both HIV and Hepatitis C was not introduced quickly enough.