Infected Blood Inquiry: Scots were studied without knowledge in scandal that 'could have been avoided'

Rishi Sunak issues ‘whole-hearted and unequivocal apology’ on ‘day of shame for the British state’

Scottish victims of the infected blood scandal were studied without their knowledge as part of a wider scandal for which Rishi Sunak has made “a whole-hearted and unequivocal apology”.

An inquiry that was established to examine the circumstances in which patients treated by the NHS in the 1970s and 1980s received infected blood found deliberate attempts were made to conceal the disaster, including evidence of Whitehall officials destroying documents.

More than 30,000 people in the UK, including about 3,000 in Scotland, contracted HIV and Hepatitis C via contaminated blood products during the 1970s and 80s.

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

Vowing to pay “comprehensive compensation”, the Prime Minister said the release of the inquiry’s findings – which identified a “catalogue of systemic, collective and individual failures” amounting to a “calamity” – marked “a day of shame for the British state”.

"At every level, the people and institutions in which we place our trust failed in the most harrowing and devastating way," Mr Sunak said in a statement to the House of Commons.

"Layer and layer upon hurt, endured across decades, this is an apology from the State to every single person impacted by the scandal.

"It did not have to be this way. It should never have been this way."

"And on behalf of this and every government stretching back to the 1970s, I am truly sorry."

The inquiry found Scottish doctors became aware of the risks of using a blood clotting treatment called Factor VIII, but did not inform their patients and instead carried out research on them instead.

Key findings from the report, and what it means for Scottish victims

Inquiry chair Sir Brian Langstaff’s explained patients in Edinburgh and Glasgow were not initially informed about the risks of Factor VIII, with doctors knowingly keeping them “in the dark”. The finding came despite Professor Christopher Ludlam insisting the testing was for routine monitoring.

Sir Brian said: “It was undoubtedly research, despite his suggesting otherwise.

"Patients were never informed of the results of the investigations and the studies led to no review of the treatment regime. It did however, lead to publications in Dr Ludlam’s name and of his colleagues.

“Had they been informed, they would also have been told why, and would have become aware of the dangers of the treatment they were receiving.

"Some or all of them may then have refused to continue to be treated with concentrates. They may not then have been infected with HIV.”

Sir Brian also concluded that Scotland’s work in the domestic manufacture of blood products could have helped the whole of the UK reach self-sufficiency. This would have helped prevent importing the dangerous blood products that tore through Britain.

The report on the infected blood scandal also laid bare “decades of gross and culpable failures”, according to a law firm which represented hundreds of Scots affected by contaminated blood.

Thompsons Solicitors, which represented 300 individuals and two charities in the Infected Blood Inquiry, said the “hard-hitting” report highlighted Scotland-specific failures that led to “so much suffering and death”.

These included, the firm said, failures in Scottish blood transfusion services in the 1980s and numerous “missed opportunities” to remedy the injustices brought about by the scandal.

Lynn Carey, associate at Thompsons, said: “We welcome the publication of the report on behalf of every Scottish victim of the contaminated blood scandal. The report is hard-hitting and in many ways difficult to read.

“Sir Brian Langstaff has laid bare the decades of gross and culpable failures that caused so much pain, suffering and death.”

The report was also critical of decisions at Yorkhill hospital in Glasgow that saw children suffering from haemophilia receive plasma products sourced from paid donors in the United States, despite these being known to be high risk. In all, 21 children become infected with HIV at the hospital.

The report attributed this to decisions taken by the-then centre director Dr Michael Willoughby, saying: “It makes little sense for Dr Willoughby to have committed Yorkhill to the purchase of commercial concentrates when throughout the period of interest Scotland was effectively self-sufficient in NHS factor concentrates.”

The report also set out that since the scandal there had been “a series of missed opportunities to remedy (in small measure at least) the injustices that had been, and continued to be, experienced.”

It listed a number of missed opportunities, including an investigation by the Scottish Executive, recommendations from the Health and Care Committee and the recommendations of an expert group appointed by the Scottish Executive, none of which, it says, were taken, resulting instead in the harm being “compounded”.

Ms Carey held up the Penrose Inquiry as a particularly prominent missed opportunity, in the eyes of victims of the scandal.

The Penrose Inquiry into infection from NHS treatment in Scotland with blood and blood products was set up by the Scottish Government in 2008 and issued its final report in 2015.

Ms Carey said: “The victims that we represent all talk of the many missed opportunities over the years for the truth to be found and justice served. We also talk about how the harms of the scandal were compounded by secrecy, cover-up and those missed opportunities.

“The Scottish victims hold the Penrose Report as a missed opportunity that compounded their harms. We have spoken of righting the wrongs of Penrose. Today that wrong has been righted and victims and their families are vindicated.”

Joyce Donnelly, representing the Scottish Infected Blood Forum, told the hearing that Sir Brian had surpassed her expectations within the report.

"These recommendations, one hopes, will be carried through to the letter, and people will receive what they should have received 20 or 30 years ago."

Scottish Conservative leader Douglas Ross called the scandal a “shameful betrayal”.

He said: “As a result, families across the UK are continuing to grieve the loss of loved ones who were given infected blood.

“It is appalling that patients in Scotland were left in the dark and continued to be the focus of doctors’ studies, even though it was clear they were putting lives at risk by continuing such research.

“Campaigners should never have had to wait this long for answers, but apologies from politicians now in charge across the UK is a positive first step”.

Scottish Labour health spokesperson Jackie Baillie said: “This harrowing report has underlined the scale of the scandal and how lives were put in danger across the UK.

“That the report has concluded that authorities deliberately acted to hide the scale of this scandal is absolutely shocking and those to blame must be held to account. The lessons of this report must be heeded to ensure that a scandal of this deadly scale must never be repeated.

Scottish Government public health minister Jenni Minto apologised.

She said: “Today is about those who have been infected, their families and support organisations, and I want to pay tribute to them. They have been focused on ensuring the impact of this terrible tragedy, their suffering, has not been ignored.

“On behalf of the Scottish Government, I reiterate our sincere apology to those who have been infected or affected by NHS blood or blood products.

“The Scottish Government has already accepted the moral case for compensation for infected blood victims and is committed to working with the UK Government to ensure any compensation scheme works as well as possible for victims".

NHS Scotland Health Boards said in a statement: “We sincerely apologise for the historical failings described in the Infected Blood Inquiry and empathise with the impact these events had on infected and affected people.

“We welcome the publication of this inquiry and we would like to thank the chair and staff for the work undertaken to produce this comprehensive report.

“Modern safety standards are rigorous and significant advancements in screening and testing protocols have been made since the events that have been the subject of this inquiry. All donated blood then undergoes thorough testing before being used for transfusions.

“NHS Scotland is committed to ensuring lessons from these events have been learned as we continue to prioritise a safe and sustainable blood supply across Scotland.”