An estimated 3,000 people in the United Kingdom are believed to have died and many others were left with lifelong illnesses after receiving blood or blood products tainted with HIV or hepatitis in the 1970s to the early 1990s.
The scandal is widely seen as the deadliest disaster in the history of Britain’s state-run National Health Service since its inception in 1948.
Former judge Brian Langstaff, who chaired the inquiry, slammed successive governments and medical professionals for “a catalogue of failures” and refusal to admit responsibility to save face and expense. He found that deliberate attempts were made to conceal the scandal, and there was evidence of government officials destroying documents.
“This disaster was not an accident. The infections happened because those in authority — doctors, the blood services and successive governments — did not put patient safety first,” he said. “The response of those in authority served to compound people’s suffering.”
Prime Minister Rishi Sunak apologised to the victims and said the report’s publication marked “a day of shame for the British state.”
Campaigners have fought for decades to bring official failings to light and secure government compensation. The inquiry was finally approved in 2017, and over the past four years it reviewed evidence from more than 5,000 witnesses and more than 100,000 documents.
Many of those affected were people with hemophilia, a condition affecting the blood’s ability to clot. In the 1970s, patients were given a new treatment that the U.K. imported from the United States. Some of the plasma used to make the blood products was traced to high-risk donors, including prison inmates, who were paid to give blood samples.
Because manufacturers of the treatment mixed plasma from thousands of donations, one infected donor would compromise the whole batch.
The report said around 1,250 people with bleeding disorders, including 380 children, were infected with HIV -tainted blood products. Three-quarters of them have died. Up to 5,000 others who received the blood products developed chronic hepatitis C, a type of liver infection.
Meanwhile, an estimated 26,800 others were also infected with hepatitis C after receiving blood transfusions, often given in hospitals after childbirth, surgery or an accident, the report said.
“I am truly sorry,” Sunak told a packed and silent House of Commons. “Today’s report shows a decades-long moral failure at the heart of our national life. From the National Health Service to the civil service to ministers in successive governments, at every level, the people and institutions in which we place our trust failed in the most harrowing and devastating way.”
He vowed to “right this historic wrong” and said details of a compensation package, expected to total 10 billion pounds ($12.7 billion), would be announced Tuesday.
The report said many of the deaths and illnesses could have been avoided had the government taken steps to address the risks linked to blood transfusions or the use of blood products. Since the 1940s and the early 1980s it has been known that hepatitis and the cause of AIDS respectively could be transmitted this way, the inquiry said.
Langstaff said that, unlike a long list of developed countries, officials in the U.K. failed to ensure rigorous blood donor selection and screening of blood products. At one school attended by children with haemophilia, public health officials gave the children “multiple, riskier” treatments as part of the research, the report said.
He added that over the years authorities “compounded the agony by refusing to accept that wrong had been done,” falsely telling patients they had received the best treatment available and that blood screening had been introduced at the earliest opportunity. When people were found to be infected, officials delayed informing them about what happened.
Langstaff said that while each failure on its own was serious, taken “together they are a calamity.”
Andy Evans, of campaign group Tainted Blood, told reporters that he and others “felt like we were shouting into the wind during the last 40 years.”
“We have been gaslit for generations. This report today brings an end to that. It looks to the future as well and says this cannot continue,” he said.
Diana Johnson, a lawmaker who has long campaigned for the victims, said she hoped that those found responsible for the disaster will face justice — including prosecution — though the investigations have taken so long that some of the key players may well have died since.
“There has to be accountability for the actions that were taken, even if it was 30, 40, 50 years ago,” she said.
