The Infected blood inquiry

Before 1996, an estimated 30,000 people in the UK were given contaminated blood transfusions and blood products infected with hepatitis C , hepatitis B and/ or HIV. More than 3,000 people have died as a result, and thousands more live with on-going health complications. 

Approximately 26,800 people received infected blood via blood transfusion. Blood transfusions, routinely used following accidents, complications in childbirth or as part of other medical treatment, put people at risk of contracting hepatitis C because donations were not routinely screened before September 1991. The Inquiry Report states that because the SHOT (Serious Hazards of Transfusion) scheme – a way for healthcare organisations to report adverse events and blood transfusion reactions – did not begin until 1996, there was still a risk of infection until this date.

The Inquiry Report states that the risk of contracting hepatitis from blood transfusions – and therefore that presence of viruses in blood – was known from at least the 1940s. Although the hepatitis C virus was not identified until 1988, it was apparent that “non-A non-B hepatitis” (as hepatitis C was formerly known), was responsible for the majority of post-transfusion hepatitis cases from at least the mid-1970s.

Sir Brian Langstaff, Chair of the Inquiry, stated that “this was not an accident”. The Inquiry Report highlights five recommendations that the World Health Organization made in 1952 to maximise blood safety; by the 1980s, the UK had not implemented a single one of these.

The Infected Blood Inquiry found that infections were caused needlessly to people who received blood transfusions by:

• Not ensuring a rigorous blood donor selection and screening process was in place. The UK continued to collect blood from prisons until the 1980s, despite knowing infection rates were higher in these blood donations
• Delaying universal screening of blood donations for HIV and hepatitis C
• Failing to warn patients of the risks of transfusions
• Giving transfusions to people when there was no real clinical need
• Failing to monitor and record blood transfusions properly, making it impossible to trace most people given transfusions
• Delaying telling patients they had hepatitis C or HIV, or that they should be tested for it.

In addition, an estimated 3,650 people with haemophilia, a condition that affects the blood’s ability to clot, and other bleeding disorders received infected blood products. This figure includes around 380 children. People with these conditions regularly received blood products as part of their treatment, most notably, Factor 8 and 9 concentrates.

Factor 8 and 9 concentrate were produced by combining human blood plasma from up to 60,000 donors and concentrating it to extract the required clotting factor. Just one contaminated blood sample could infect the entire batch.

The use of blood products in treatment in the 1970s meant that the demand for blood donations could not be met domestically. As such, the NHS sourced around 50% of its supply of Factor 8 concentrate from overseas, including countries such as Austria and the USA.

The final report of the Infected Blood Inquiry found that infections were caused needlessly to people with bleeding disorders by:

• Allowing the importation and distribution of Factor 8 made in the USA or Austria from blood from paid donors; blood from paid donors has much higher levels of blood-borne viruses
• Not ensuring that there was a sufficient supply of UK donors to meet the demand for Factor 8 without having to import products
• Increasing the limits on the number of donations Factor 8 and 9 products could be made from (these products were made from hundred, sometimes thousands, or blood donations), despite knowing this would increase the chance of infection
• Failing to tell patients about the risks and possible alternatives
• Conducting research on people without telling them, including the children at Treloar’s College, a boarding school with an on-site NHS haemophilia centre
• Failing to tell people they had hepatitis C and/or HIV, denying them the opportunity to manage their illness and to prevent transmission to those close to them.

The Inquiry also found that the Government, civil service and NHS – instead of working to support those affected – over decades tried to cover up and deny these actions.

The Inquiry Report describes people who contracted HIV or hepatitis C via contaminated blood as facing a huge amount of stigma. The AIDS crisis and lack of understanding about how the viruses were transmitted meant that many people lost jobs, friends and relationships.

There were also often financial implications attached to the new health challenges that came with infection. All of this had a serious impact on many people’s mental health.

Even today, the stigma attached to hepatitis C means that some people affected by the contaminated blood scandal do not speak about it. This can increase feelings of isolation and loneliness.