Britain’s infected blood scandal could “largely, though not entirely, have been avoided” had it not been for a “catalogue of failures” and a cover-up to hide the truth, a long-awaited report into the “worst treatment disaster in the history of the NHS” has reported.
More than 30,000 people were given blood or blood products contaminated with HIV, hepatitis C, or both, between the 1970s and 1990s - including an estimated 3,000 in Scotland.
Prime Minister Rishi Sunak Mr Sunak is expected to issue an apology on behalf of the UK Government on Monday evening.
Details of a compensation package - expected to be more than £10 billion – are likely to be set out on Tuesday.
Scotland's Public Health Minister, Jenni Minto, has said she will work with the UK government on the redress.
READ MORE: Infected blood scandal: Thousands of lives still blighted
In his damning report, Sir Brian Langstaff, chair of the Infected Blood Inquiry said that despite knowing of the risk of infection there had “systemic, collective and individual failures to deal ethically, appropriately, and quickly” by clinicians and politicians.
This, he said, had “consequences for thousands of families.”
Around 3,000 deaths are attributable to infected blood, blood products and tissue, while 4,000 to 6,000 people were left with bleeding disorders, and around 1,250 were infected with HIV, including 380 children. Of those, around 75% died.
Almost all of those infected with HIV were also infected with Hepatitis C and some with Hepatitis B and Hepatitis D as well.
Approximately 26,800 were infected with Hepatitis C after a blood transfusion, often linked with childbirth or surgery, but also from transfusions to treat thalassemia, sickle disease, or leukaemia, or tissue transfer.
Sir Brian said the scale of what had happened was “horrifying.”
He blamed failures in the licensing regime, in particular allowing the importation of blood products made in the US or Austria which carried a high risk of causing hepatitis.
He also blasted the failure to ensure sufficiently careful and rigorous donor selection and screening, which saw the collection of blood from prisons.
Sir Brian said children were treated as “objects for research” and often patients were simply not told about the risks of their treatment or of the alternatives.
He said the inquiry became aware of some cases where people were not told that they were infected “thereby denying them the opportunity to control the progression of their own illness more effectively and to prevent the spread of infection to others close to them.”
Sir Brian also criticised the Prime Minister’s insistence on waiting for the conclusion of his inquiry before making a final decision on redress.
“When the Government knows, as it clearly does, that what happened was a terrible injustice, that people deserve redress, and that lack of redress perpetuates the injustice, then to delay, and thus deny, justice in order to await the ‘full context’ seems hard to justify.”
The report also castigated the lack of action from previous governments.
In the 1980s, Margaret Thatcher's government decided against any form of compensation to people infected with HIV, with Ken Clarke, who was health minister at the time, saying there would be no state scheme to compensate those suffering “the unavoidable adverse effects” of medical procedures.
Then-prime minister Margaret Thatcher rebuffed calls for compensation by asserting in 1989 that people infected with HIV from blood products “had been given the best treatment available on the then current medical advice”.
The repeated use of this mantra by ministers and officials over the next 20 years, including about people infected by other diseases, was “wrong” and “amounted to blindness”, according to Sir Brian.
It was only in 2017 when Theresa May finally announced an inquiry.
READ MORE: 'We are still suffering', say families of contaminated blood scandal victims
The report made a number of criticisms over what happened in Scotland, including poor facilities and inadequate staffing at regional transfusion centres, as well as a failure to introduce testing.
The Protein Fractionation Centre in Edinburgh was set up in the 1970s in order to produce blood products for use in Scotland and the north of England, but was never used for this purpose.
The report found that this contributed to a failure to supply enough Factor VIII plasma from UK donors to meet foreseeable demand, leading to a need to import plasma from abroad.
The report was also critical of decisions at Yorkhill hospital in Glasgow that saw children suffering from haemophilia receive plasma products sourced from paid donors in the United States, despite these being known to be high risk.
In all, 21 children become infected with HIV at the hospital.
Lynn Carey, associate at Thompsons, which represented 300 individuals and two charities in the Infected Blood Inquiry, said Sir Brian had "laid bare the decades of gross and culpable failures that caused so much pain, suffering and death.”
Ms Carey said: “The victims that we represent all talk of the many missed opportunities over the years for the truth to be found and justice served. We also talk about how the harms of the scandal were compounded by secrecy, cover-up and those missed opportunities."
Ms Minto welcomed the publication of the inquiry’s report and apologised on behalf of ministers in Edinburgh.
She said: “Today is about those who have been infected, their families and support organisations and I want to pay tribute to them. They have been focused on ensuring the impact of this terrible tragedy, their suffering, has not been ignored.
“On behalf of the Scottish Government, I reiterate our sincere apology to those who have been infected or affected by NHS blood or blood products.
“The Scottish Government has already accepted the moral case for compensation for infected blood victims and is committed to working with the UK Government to ensure any compensation scheme works as well as possible for victims.”
Ms Minto said the government had set up an oversight group to consider the inquiry’s recommendations for Scotland.
Scottish Labour health spokesperson Jackie Baillie said: “This harrowing report has underlined the scale of the scandal and how lives were put in danger across the UK.
“My thoughts and those of the entire Scottish Labour Party are with all of those who have been affected by this scandal – including those still living with the consequences today.
“That the report has concluded that authorities deliberately acted to hide the scale of this scandal is absolutely shocking and those to blame must be held to account.
“The lessons of this report must be heeded to ensure that a scandal of this deadly scale must never be repeated.
“Those affected by this scandal must be properly compensated and steps should be taken to ensure the culture of secrecy in the NHS is eradicated.”
Scottish Conservative leader Douglas Ross said: “This is a momentous day for campaigners who have fought tirelessly for justice and have been wholly vindicated by this devastating report.
“It exposes a shameful betrayal of thousands of people by institutions that they understandably put their trust in. As a result, families across the UK are continuing to grieve the loss of loved ones who were given infected blood.
“It is appalling that patients in Scotland were left in the dark and continued to be the focus of doctors’ studies, even though it was clear they were putting lives at risk by continuing such research.
“Campaigners should never have had to wait this long for answers, but apologies from politicians now in charge across the UK is a positive first step.
“I encourage both governments to now work closely together to see how financial compensation can be delivered as quickly as possible to all those affected, who were so shamefully let down by those in positions of power.”
An earlier probe in Scotland, known as the Penrose Inquiry, was branded a "whitewash" by campaigners when it published its findings in 2015 and made just one recommendation - that blood tests be offered to anyone in Scotland who had received a blood transfusion prior to 1991 and who had not already been tested for Hep C.
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