On 20 May, the Infected Blood Inquiry published its report on the infected blood scandal. The report has been welcomed by campaigners and affected communities.
Sir John Glen, Paymaster General, is expected to make a detailed announcement of the new compensation system for the people affected on Tuesday 21 May.
The report sets out a catalogue of failures by MPs, civil servants, clinicians, the NHS and successive Governments over almost fifty years. Sir Brian Langstaff, chair of the Inquiry, received a standing ovation from attendees at the launch. He opened: “This disaster was not an accident”.
The Inquiry found that much of the harm caused through in Infected Blood Scandal could have been prevented, and the majority of infections could and should have been avoided.
A huge number of failings are identified through the report. These include:
- Failures in medicines licensing in allowing the import and distribution of commercial blood products, such as factor 8 concentrates, known to carry a high risk of hepatitis and to be less safe than UK-produced treatments.
- The Government allowing increases in pool sizes for UK-produced factor 8 and factor 9 treatments, increasing the risks of viruses.
- Clinicians failed to make change treatment regimes to make them safer for patients receiving blood products, and used transfusions when not clinically needed.
- Children being treated with riskier commercial concentrates and used as “objects for research”.
- Failures to implement donor selection and screening and delays in introductions of testing of blood.
- Failing to tell people the risks associated with blood products and transfusions, to gain informed consent, and failures to tell people of their hepatitis and/or HIV diagnoses for weeks, months or in some cases years.
The report has twelve overarching recommendations:
- A compensation scheme should be set up immediately and as detailed in the Interim Report on Compensation published in April 2023.(Recommendation 1)
- A permanent memorial should be established, and a series of events should be held to bring the affected communities together. Both should be planned with people affected. (Recommendation 2)
- People who received a blood transfusion before 1996 should be offered a hepatitis C test by their GP, and patients should be routinely asked if they have had a blood transfusion at GP registration.(Recommendation 8)
- People given hepatitis C and have liver damage (fibrosis or cirrhosis) should have access to regular monitoring, and local health services should publish the steps they are taking to ensure they’re meeting the needs of people harmed by NHS treatment. (Recommendation 6)
- The lessons to be learned should be incorporated into every doctor’s training. (Recommendation 4)
- There should be a statutory Duty of Candour for all UK nations, and these should be extended to people in leadership and Board positions in the health service.(Recommendation 4)
- Ending the defensive culture in the Civil Service and Government, including a review to assess whether there should be legal duties for openness and accountability (Recommendation 5)
- Haemophilia care should be routinely peer-reviewed, the findings of those reviews should be required to be acted on by hospital trusts (Recommendation 9)
- Recombinant coagulation products should be offered in place of plasma-derived products where clinically appropriate.(Recommendation 9)
- Patient voice must be improved through routine collection of patient satisfaction data (Recommendation 10)
- Funding should be provided for patient advocacy groups and charities supporting infected blood communities.(Recommendation 10)
- In addition to existing powers under the Inquiries Act 2005 for ministers to announce public inquiries, there should also be a mechanism for parliament to refer the need for a public inquiry to the Public Administration and Constitutional Affairs Committee (Recommendation 11)
- The Government should respond in detail to the recommendations, either accepting these or explaining in detail why they cannot this year. (Recommendation 12)
- Progress towards implementing the recommendations should be reviewed by the Public Administration and Constitutional Affairs Committee. (Recommendation 12)
Sir Brian Langstaff explained that he has written to the Government, stating that the Inquiry is not yet closed and – in line with the Inquiry terms of reference – will remain open until Sir Brian is satisfied that the Government is making an adequate response.
We are anticipating a statement from John Glen, Paymaster General and Minister with responsibility for the Compensation system, at 12.30 on Tuesday 21 May.