'Catalogue of failures': The missed opportunities in the infected blood scandal

Words by Sophia Ankel

A long-awaited final report from the public inquiry into what has been considered the "biggest treatment disaster in NHS history" was published on Monday.

The seven-volume report outlines what it described as a "catalogue of failures that could largely have been avoided and should have been."

The scandal saw more than 30,000 people infected with Hepatitis C and HIV after being treated with contaminated blood products during the 1970s and 1980s.

At the time of writing, around 3,000 people are believed to have died as a result of the mistreatment - among them 380 children.

"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 chair of the inquiry, former judge Sir Brian Langstaff, said in a statement issued alongside the report.

The inquiry process has no scope to determine civil or criminal liability.

However, the report did name responsible bodies involved, and outlined how they failed to prevent the disaster from unfolding.

ITV News breaks down these missed opportunities.

1. Knowledge of risk of infection from blood and blood products

The risks of blood and blood products causing severe infection were "known well before most patients were treated," the report found.

The fatal risks of Hepatitis C, for example, were already known since World War Two, where the blood-borne virus spread easily among soldiers who were being treated in unsanitary field hospitals.

By the mid-1980s, Aids emerged as a further threat to the safety of blood supply and blood products, which the Department of Health and Social Security (DHSS) was "well aware" of, according to the report.

Despite this, no steps were taken by the department to ensure that the serious nature of these conditions was understood by doctors, patients, representative bodies, or the public.

2. Failure to achieve self-sufficiency in blood products and stop imports

Despite recommendations from the World Health Organisation (WHO) and attempts by the government, the UK "failed to achieve self-sufficiency in blood products," the report found.

As a result, blood products were mostly imported from the United States, which took blood from high-risk paid donors, such as prisoners and drug addicts.

By mid-1982, the government was aware that the imported commercial blood products - known as factor 8 concentrate - carried a high risk of hepatitis and were less safe than domestic treatments, of which there should have been a sufficient supply.

Despite this, it still decided not to suspend the importations in 1983, and increased the size of pools to manufacture the treatment, instead - markedly increasing the risks of viral transmission even more.

3. Failure to stop prison donations and conduct rigorous donor selection

While much of the focus of the inquiry was on blood products imported from the US, the report also makes clear there were issues with domestic prison donations.

Blood collection from prisons was a common practice in the UK throughout the 1970s and early 1980s.

This was despite reported evidence there is a much higher incidence of hepatitis among prisoners than amongst the rest of the donor population.

Yet, no action was taken to stop donations or discourage them.

The report says that UK blood services "failed to ensure sufficiently rigorous donor selection and screening of blood donors."

Additionally, the "testing of blood donated in the UK was not introduced as quickly as it could have been, and surrogate screening methods, which could have been used before those tests were available, were not adopted," it added.

5. A 'doctors know best' mentality

Doctors treated patients despite the known risks of viral transmission and without informing them of those risks, the report also found.

They gave false reassurance to patients, and failed to adjust their treatment regimes to make them safer when such adjustments were possible, it added.

In some cases, patients were tested without their knowledge or consent and not informed of the result, sometimes for years.  

6. Cover-up culture

The NHS' and ministers’ refusal to own up to their failings “served to compound people’s suffering,” resulting in a decades-long battle for the truth, the report found.

It took until 2018 for a UK-wide public inquiry to be established, and up until then successive government claimed that there was no wrongdoing.

Ministers “cruelly” repeated the line from Margaret Thatcher in 1989 that “they had received the best treatment available” and therefore that compensation was not required, the report found.

On top of this, they failed to deliver a meaningful apology

A formal response by Government is expected to be limited on Monday as campaign groups have called for it to be be a day for the victims and families.

But it is expected that billions in compensation could be made available to victims, and that Rishi Sunak will make an official apology to all victims on behalf of the Government.

The report said: "A full apology from government is to be expected, but for that apology to be meaningful, it must be accompanied by action.

"There must be national recognition of this treatment disaster and compensation without further delay, as well as implementation of the Inquiry’s recommendations for a change of culture and practice in the NHS and the Civil Service."

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