Infected Blood report: Here are the key findings from the Inquiry report and what it means for Scottish victims

The long-awaited Infected Blood Inquiry report was finally published on Monday.

The Infected Blood Inquiry has found a “catalogue” of failures which led to a treatment “disaster” that could and should have been avoided.

Established to examine the circumstances in which patients treated by the NHS in the 1970s and 1980s received infected blood, the inquiry also investigated the impact on families, how the authorities responded, and the care and support provided to the infected.

Former prime minister Theresa May had announced the inquiry in 2017, which has now found failures from successive governments, as well as other parties. Here are the key findings from a damning report that exposes a culture of cover-ups, denials and evidence of crucial documents being destroyed.

Some of the victims of the infected blood scandal. Pictures: PA

The key statistics

Between 1970-2019, around 1,250 people with bleeding disorders were infected with HIV, including 380 children. Of those, around 75 per cent died.

Around 80 to 100 people were also infected with HIV through transfusions, of which 85 per cent died. A total of 26,800 people were infected with the Hepatitis C virus (HCV) through blood transfusions, of which 22,00 were chronically infected. Just 8,130 of these survived ten years after transfusion, and only 2,700 were left by the end of 2019.

HCV infections in Scotland reached 2,740, compared to 22,000 in England. Wales saw 1,320 infections, and there were 730 in Northern Ireland. Experts concluded around 2,900 deaths are attributable to infections from blood or blood products in the UK.

Chairman of the infected blood inquiry Sir Brian Langstaff with victims and campaigners outside Central Hall in Westminster, London, after the publication of the Inquiry report. Picture: Jeff Moore/PA Wire

The Treloar scandal

One of the most appalling scandals relates to Treloar’s College – a school for the disabled in Hampshire. Children attending were offered treatment for haemophilia between 1970 and 1987. Of the 122 pupils, just 30 survived.

Those who did explained there was no consultation with parents about treatment or details of the risks provided, despite these being well known to Treloar's clinicians.

None of the boys were told they were being tested for HIV, nor that before they had been checked to see whether they had any signs they were developing Aids. When it emerged in late 1984 there were infections, Treloar’s clinicians told the boys it had been an unavoidable accident.

Victims and campaigners outside Central Hall in Westminster, London, after the publication of the Inquiry report. Picture: Jeff Moore/PA Wire

How did this happen?

It was well known from at least the early 1940s that blood transfusions or the use of plasma could transmit “serum hepatitis”, and Hepatitis was identified by the early 1970s. Similarly, it was apparent by mid-1982 that whatever was causing Aids might be transmissible through blood or blood products.

Despite this, the report found comprehensive failures in the licensing regime for the importation of blood products, leading to the importation of blood products from the US or Austria known to be less safe. By failing to achieve self-sufficiency, the pools used to create blood products in Britain were made bigger, with it being well known this would increase the risk of viral transmission.

There was also a lack of screening for donors, not pursuing research for safer products, and failing to adjust once the impact was known. The public and patients were then lied to about blood not carrying Aids, as well as over the risks. People were also not informed about alternative treatments and, in many cases, not even told they were infected.

There was also a criticism of the decision in July 1983 not to suspend the continued importation of commercially produced blood products. Screening for HIV and Hepatitis C was also delayed, and a chance to screen high risk donors with surrogate testing was simply ignored.

Throughout the crisis, patients were not told the risks, and the NHS and governments were accused of a lack of transparency, and refusing compensation for a long time on the grounds there was no fault.

The Government response

It was the responsibility of the Department of Health and Security (DHSS), and of the Secretary of State for Health and of those in positions of equivalent responsibility in Scotland, Wales and Northern Ireland, to ensure, as much as possible, that treatment given through the NHS was safe.

However, despite knowing blood from prisons and similar institutions led to an increased risk of transmission of Hepatitis B, they continued to use it. This issue was not raised with a Scottish minister until May 1983, and it was never raised with ministers in the DHSS.

The report also highlighted a belief the risks of transmission were unproven, and at no point up to May 1983 were issues relating to Aids and blood brought to ministers.

This stubborn failure to ignore evidence is epitomised by a resolution from the Council of Europe’s Committee of Ministers, calling for states “to take all necessary steps and measures with respect to” Aids. The first detailed recommendation was “to avoid wherever possible the use of coagulation factor products prepared from large plasma pools; this is especially important for those countries where self sufficiency in the production of such products has not yet been achieved”. The UK government took no steps in response to this recommendation. The second recommendation was to tell clinicians and patients about the risks of treatment with blood and blood products and the possibilities of minimising the risks. This was also ignored.

May 1983 saw the first "no conclusive proof" line from the Prime Minister, who said there was no evidence Aids was being transmitted from American blood products. This line gave false reassurance, was misleading, and failed to reflect the actual understanding in Government, the report found. Quietly dropped at the end of the year, no minister ever challenged the line.

On Hepatitis C screening, the inquiry found it should have been introduced by March 1990. It wasn’t.

The report said five features characterised the government response. First, any financial support has been in response to intense parliamentary, media and/or public pressure. Secondly, the government response was too slow, thirdly they sought to do the least possible. The fourth feature was insisting they had done nothing wrong, and then refusing to learn any lessons from it.

The cover-up

According to the report, there was a deliberate decision to destroy Department of Health files which contained material dealing with delays in the introduction of screening blood donations for Hepatitis C.

The files, which related to decision-making of the Advisory Committee on the Virological Safety of Blood (ACVSB), were marked for destruction in 1993.

Chairman of the inquiry, Sir Brian Langstaff, said: “The destruction was not an accident, nor the result of flood, fire or vermin. The immediate reason for destruction was human choice. Someone, for some reason, had chosen to have those documents destroyed.

“It is an uncomfortable conclusion that it is more likely than not that a civil servant chose to destroy the documents because they were those documents. But if that is what the evidence amounts to, it is the conclusion that must follow.”

The report cites the majority of records were lost due to incompetence, a lack of proper systems, and an insistence on paper records. This lack of medical records has made it difficult for some to apply for compensation.

What it means for Scotland

Scotland had its own separate health and transfusion services, as well as a large degree of independence in matters of health policy and administration.

It found there was every reason to suppose that decision makers in Scotland became aware of the risk of Aids at broadly the same time as the DHSS in Westminster. It was thus unlikely to be long before it reached blood donors in Scotland, and thus transfused patients, and people with bleeding disorders, unless effective precautions were taken. Despite this, there was little sense of the need for urgent action.

The inquiry found no action being taken to minimise the risk of Aids, and despite a briefing being set to the minister in May 1983, no specific steps were taken, nor were they asked to make a decision.

The recommendations

The Infected Blood Inquiry has demanded a full apology from the government, but says for it to be meaningful, the response must be accompanied by “action”.

The report calls for national recognition of the treatment “disaster”, as well as an implementation of the inquiry’s recommendations for a change of culture in the NHS and civil service.

Another demand is a compensation scheme to be set up now, with the UK government also urged to report back within 12 months on its progress implementing the recommendations.

Permanent memorials are also recommended, with consideration for one in each of Scotland, Northern Ireland and Scotland. Another memorial should be established specifically for the children infected at Treloar’s school.

There should also be at least three events, about six months apart, drawing together those infected and affected.

A statutory duty of candour in healthcare should be introduced in Northern Ireland, and the operation of duties of candour in Scotland and in Wales should be reviewed, as is being done in England. This should be completed no later than 2026.

There are also calls for more accountability, with those in leadership positions required to respond to any concern about the healthcare being provided. Any person who a report is made to should then be held personally accountable for a failure to consider it properly, the report has recommended.