Nnothing can bring back the three thousand or so people who died as a result of contaminated blood products provided to them by the NHS from the 1970s to the early 1990s. Thousands of others continue to struggle with viruses contracted in the same way, while others live with the knowledge that loved ones, including children, have needlessly died or been infected. The report of the investigation into contaminated blood, which was published on Monday, is long overdue. Victims of this shameful episode were fobbed off for decades before then Prime Minister Theresa May agreed to a public inquiry in 2017.
That decision was made under strong pressure from activists. Andy Evans, who was infected with hepatitis C and HIV as a child, has described the official response as ‘kicking and screaming’. The statement from the inquiry’s chairman, Sir Brian Langstaff, was greeted with a standing ovation on Monday. But the campaigners’ relief is accompanied by anger and sadness. Truth, justice and accountability should not have been delayed for so long.
As Prime Minister, Rishi Sunak was tasked with delivering the formal apology the victims deserved. In the House of Commons he called it “a day of shame for the British state”. Given the timing, compensation is more likely to be paid out under Labor. But this scandal cannot be blamed on one party, and it concerns both civil servants and politicians. Sir Brian said officials’ thwarting of a minister’s proposal for financial support was reminiscent of Yes, Minister, and blamed Whitehall for a theme of “institutional defensive posture”.
He also criticized the lack of a ‘patient safety culture’ in all four UK health services. (Although Scotland is included in its report, a separate Scottish investigation has already taken place.) Decisions to license commercial blood products from the US, based on pooled donations, were wrong, given what was known about the risks. Screening of blood for hepatitis C should have been introduced earlier. Haemophilia expert Prof Arthur Bloom gave flawed advice, minimizing the risk of HIV infection from the factor VIII used to treat bleeding disorders.
Probably the most shocking episode took place at Treloar’s, a special boarding school in Hampshire. There, boys with hemophilia were used as guinea pigs by doctors who prioritized research over their own interests and did not ask permission.
Such actions, together with the repeated cover-up, mean the wider ‘disaster’ should not be seen as coincidental, Sir Brian said. Decisions on criminal prosecution, which remain possible, fall outside the scope of his investigation. But the report makes a series of recommendations, including the introduction of a new legal duty of candor for healthcare leaders and public servants. Aware of ministers’ patchy record in following up on previous public inquiries, Sir Brian told victims he intends to stay.
Andy Burnham, former Health Secretary and Mayor of Manchester, has previously blamed the Treasury for past inaction. He said expected costs of up to £10 billion were the reason, along with “reputational interests”. None of these motives are unique to contaminated blood research, and Sir Brian pointed out parallels with the miscarriages of justice linked to the Post Office’s flawed Horizon system.
But the time it has taken for those whose lives were destroyed by tainted blood to obtain any measure of justice puts this scandal in a class of its own. It is very worrying that politicians, civil servants and doctors are not only involved in the original poor treatment of a vulnerable group of patients, but also in a long struggle to bury the truth.
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