Victims of the infected blood scandal have welcomed the inquiry’s final report published on Monday but have said findings came “30 years too late”.
Sir Brian Langstaff, chairman of the inquiry, found that a “catalogue of failures” led to 30,000 people being infected by contaminated blood products, compounded by a “subtle, pervasive and chilling” cover-up of the truth.
The 2,527-page report was the result of a seven-year investigation into how tens of thousands of people in the UK were given blood and blood products contaminated with HIV or Hepatitis in the 1970s and 1980s.
It has been called the biggest treatment disaster in NHS history.
Debbie Kemp, whose late mother Susan Wakeling was infected with Hepatitis C after a blood transfusion in 1972, said: “The report details that the disaster was no accident. People trusted the NHS and the treatment they were being given. They trusted the people giving them care such as consultants and doctors, but their trust was betrayed.
“Hearing that the whole thing was largely preventable causes many emotions but mostly anger as those most responsible have probably already reached the end of their lives without having to take accountability or face justice. The government delays and denials over the years allowed them to get off scot-free.
“Finding out that documents were deliberately destroyed by civil servants as an effort to cover up the wrong doings makes you doubt the whole system.
“It’s quite bittersweet because the report is everything everyone wanted but 30 years too late.”
Sir Langstaff found that the scandal “could largely have been avoided” and that victims were repeatedly failed by doctors, the NHS, and the government.
The chairman said: “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. The response of those in authority served to compound people’s suffering.
“The government is right to accept that compensation must be paid. Now is the time for national recognition of this disaster and for proper compensation to all who have been wronged.
“Patients were knowingly exposed to unacceptable risks of infection. This is not a question of hindsight. The risks of blood and blood products causing severe infection were known well before most patients were treated: in the case of hepatitis since the end of the Second World War.”
Dean King, of Ridgewell, near Haverhill, was given hepatitis C through treatment for his haemophilia B, a blood clotting disorder, when he was less than 10 years old.
Like Mrs Kemp, he too was grateful for Sir Langstaff and his team for their thorough report, exposing severe failings at multiple levels.
Mr King said: “They’ve left us in no doubt that it was massive injustice, a huge cover up that was endemic and has been across successive governments, and now there’s nowhere to hide. It’s out there now in the public domain and the government has to act.
“There’s still an element of 30 years too late, though. The failure to act and be honest has caused a lot of pain and suffering, and cost people their lives.
“I feel that people who are implicated with responsibility here, who clearly did wrong, should face accountability but it feels like we’re on the right path.”
The inquiry found that there had been attempts to destroy evidence relating to infected blood.
Department of Health documents looking at delays in the screening of blood donations for hepatitis C were marked for destruction in 1993, for example.
Sir Langstaff was also highly critical of a “culture of defensiveness” within the NHS, civil service, and government, delaying accountability and justice from being served.
He continued: “The damage caused has been compounded by the reaction of successive governments, the NHS and the medical profession. To save face and expense, successive governments refused to admit responsibility, showing little interest in finding the truth, listening to those infected, or taking action.
"Many of those infected and affected by this disaster, in addition to dealing with the consequences of the original infection, have been forced into a decades long battle for the truth. Successive governments claimed that patients had received the best medical treatment available at the time, and that blood screening had been introduced at the earliest opportunity. Both claims were untrue.”
The inquiry did not have the powers to recommend criminal convictions but made 12 recommendations including compensation, a “culture change” in the NHS to prevent cover-ups and acknowledge mistakes, and a review of healthcare regulatory bodies.
Prime Minister Rishi Sunak addressed the House of Commons on Monday evening.
He said: “This is a day of shame for the British state.
“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.
“They failed the victims and their families and they failed this country."
The Conservative leader continued: "Today I want to speak directly to the victims and their families - some of whom are in the gallery."
"I want to make a wholehearted and unequivocal apology to victims."
Mr Sunak promised to pay "comprehensive" compensation to those infected and affected, with details due to be set out tomorrow.
The Prime Minister also said the government would consider carefully all the report's recommendations and respond to Parliament in due course.
But for Mark Lawler, whose late mother Margaret was infected with Hepatitis B and C from a blood transfusion, a government apology is not enough.
Mr Lawler said: “I think it’s extremely rich that the government has said they’ll make an apology. For me, it seems they’ve been chastised in the report and they know full well that they need to eat humble pie and admit their wrongdoings.”
The government is expected to announce details of compensation for victims of the infected blood scandal in the coming days.
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