The Infected Blood Inquiry Report

Priya Malhotra considers the key findings of the report and what it means for those known to be affected.

In July 2017, the former Prime Minister Theresa May announced an Inquiry into the use of infected blood and infected blood products. Today, Sir Brian Langstaff issued his report into the use of infected blood products by the NHS predominately between 1970 and 1998.

The Chair of the Inquiry has found “a catalogue of failures” which taken together he describes as a calamity, which could have largely been avoided, and should have been. He describes the scale of what happened, as horrifying – so what did happen?

In the 1940s, blood transfusions or the use of plasma, could transmit serum hepatitis; it was known this could be fatal or cause long-term disease, liver failure, cirrhosis and cancer. The virus responsible for Hepatitis B was identified by the early 1970s and the virus responsible for Hepatitis C in 1988. By mid-1982, it was apparent that AIDS might be transmissible by blood and blood products – so how could this happen?  

The Chair has found there were failures in the licensing regime, particularly regarding the importation and distribution of blood products made in the United States or Austria from 1973, which were used in the treatment of those with bleeding disorders. This was precipitated by a failure to ensure a sufficient supply of blood products from within the UK because of the “inept, fragmented system by which blood services of England and Wales operated.” The Chair further found failures to ensure sufficient careful and rigorous donor selection and screening, and an attitude of denial towards the risks, as well as continued treatment of patients despite increased risks of viral transmission. Additionally, falsely reassuring the public and patients that blood did not carry AIDS and the risk of transmission of non-A non-B Hepatitis (Hepatitis C) was relatively mild and inconsequential. In July 1983 a decision was made not to suspend the continued use of imported commercially produced blood products, a decision which was not kept under review; a further failing identified by the Chair. It has also been found that there was a failure to warn patients of the risk of treatment and available alternative treatments, thereby treating patients without informed consent and giving too many transfusions when they were not clinically needed. Further, repeated use of inaccurate, misleading and defensive lines which cruelly told people they had received the best treatment available, compounded by a lack of openness, transparency and candour “by the NHS and government, such that the truth has been hidden for decades”. This included the deliberate destruction of some documents and the loss of others. These were just some of the failings found – so what does this mean for those affected?

The Report acknowledges the Governments moral case for compensation in December 2022 and the Chair’s own recommendation in the Inquiry’s Second Interim Report dated 5 April 2023 for compensation; a compensation scheme should be set up and this remains the primary recommendation of the Inquiry. It calls for a sincere and meaningful public apology for the greatest treatment disaster in the history of the NHS. Further, a recommendation for a permanent memorial to be established. It further recommends action by the General Medical Council, NHS Education for Scotland, Health Education and Improvement Wales, Northern Ireland Medical and Dental Training Agency and NHS England, should ensure the lessons learned from the Inquiry are incorporated into every doctor’s training. Additionally, an end to a culture of defensiveness, lack of openness and being dismissive of concerns about patient safety. Further a duty of candour on senior civil servants and ministers. The Report calls for external regulation of safety in healthcare to be simplified across the UK and the Devolved Administrations. A recommendation for monitoring liver damage for those infected with Hepatitis C and what form future monitoring should take. The Inquiry invites the Government to consider and either commit to implementing the recommendations in the Report within 12-months or give sufficient reason for why one or any of the recommendations in the Report are not to be implemented. At the time of writing, it remains to be seen how the current Government will respond.