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The scandal that caused thousands of people in the UK to become infected or die from contaminated blood was avoidable and inflamed by a “subtle, pervasive and chilling” cover-up by the NHS and government, a scathing report has concluded.
In the long-awaited conclusion to a five-year public inquiry, Sir Brian Langstaff, who chaired the investigation, said the calamity could “largely, though not entirely, have been avoided” – but successive governments and others in authority “did not put patient safety first”.
More than 30,000 people in the UK, 3,000 of whom have died, were infected with tainted blood from the 1970s through to the early 90s, either from receiving transfusions during surgery, or through products created using blood plasma and imported from the US to treat haemophiliacs.
Speaking on Monday in Westminster Central Hall, near parliament, to launch the report, Langstaff was given a standing ovation by more than 1,000 infected and affected people when he walked in.
“The inquiry is not just investigating something which happened years ago. It is still happening,” he said.
“People still have to care for the after-effects of what happened, which their loved ones still suffer. The grief and trauma which all of those who lost loved ones experienced continues to this day … Every aspect of their lives has been defined by their infections – childhood; education; career; leisure; relationships; marriages; home ownership; travel; finances; dreams and ambitions have been lost and relationships broken.”
The 2,527-page final report found that patients were lied to about the risks and, in some cases, infected during research carried out without their consent, or, in the case of children, that of their parents. There were also delays informing patients of their infections, stretching to years in some cases.
Langstaff said the risks of hepatitis posed by blood transfusions or the use of plasma were known prior to the NHS’s inception in 1948, while importation of factor VIII products should never have been licensed in 1973.
“The risks of hepatitis were freely admitted by the makers, he said. “I have concluded the UK was wrong to decide to license these products in 1973, and later decisions in the 1970s to grant further licences for similar US products were also wrong. These products should simply not have been permitted to be distributed generally in this country.”
He said the treatment failures were compounded by denial and obfuscation. This included the “misleading” oft-repeated statement that there was “no conclusive proof” that Aids could be transmitted by transfusion of blood and blood products when the HIV epidemic emerged in the 1980s and, later, the deliberate destruction of official documents.
Langstaff condemned a culture in which “financial and reputational considerations predominated”, with the present government also criticised for its failure to fully implement recommendations on compensation.
“Standing back and viewing the response of the NHS and of government, the answer to the question ‘was there a cover-up?’ is that there has been,” he wrote. “Not in the sense of a handful of people plotting in an orchestrated conspiracy to mislead, but in a way that was more subtle, more pervasive and more chilling in its implications. To save face and to save expense, there has been a hiding of much of the truth ….
“Over decades successive governments repeated lines to take that were inaccurate, defensive and misleading. Its persistent refusal to hold a public inquiry, coupled with a defensive mindset that refused to countenance that wrong had been done, left people without answers, and without justice. This has also meant that many people who are chronically ill have felt obliged to devote their time and their energies to investigating and campaigning, often at great personal cost.”
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The report contains a litany of examples of research, health bodies, internal government warnings, and the press, raising the alarm about the risks posed by contaminated blood – only for doctors and ministers to fail to change tack.
For example, in 1952, the World Health Organization reported “serum hepatitis” as a serious problem and suggested five measures to reduce the risk, which Langstaff said, if adopted “it is reasonable to believe that a significant part of the harm on which this inquiry is focused could have been prevented”.
While hepatitis C was not formally identified until 1988, the risk it posed was apparent from at least the mid-1970s, Langstaff found.
With Aids, the report says that it was apparent by mid-1982 to “some clinicians and some within government” that whatever was causing it might be transmissible by blood and blood products.
Despite this, there were failures to ensure rigorous donor selection and screening, with the continued collection of blood from prisons, where donors were high-risk, delays in screening and false reassurances provided to patients. In July 1983, a decision was taken not to suspend the continued importation of commercially produced blood products.
Langstaff said: “The evidence before the inquiry overwhelmingly establishes that people with bleeding disorders were not properly advised of the risks of hepatitis or Aids. They had the right to know that factor concentrates might infect them with a serious or fatal disease for which there was no treatment. Parents had the right to know what such treatments might infect their children. In practice, either they were given no information at all about such risks, or they were falsely reassured that the treatments were safe.”
He said it was the time for national recognition of the disaster and for the government to pay proper compensation “to all those who have been wronged”. Paying tribute to those infected and affected, he said they had “told powerful stories of pain, sickness and loss, of lives damaged and destroyed, unrecognisable from before their infection and unrecognisable from all their hopes and dreams for their lives”.
