The Infected Blood Inquiry’s final report has been published

The final report of Sir Brian Langstaff (“Sir Brian”), the Chair of the Infected Blood Inquiry (“the Inquiry”), has been published today.

This report has been long-awaited, with the Inquiry first having been announced by the Government in July 2017, following pressure from campaigners for an investigation into contaminated blood after over 40 years.

The Inquiry

The Inquiry was established to investigate the circumstances in which, particularly from the 1970s to 1990s, contaminated blood and blood products were used by UK National Health Services to treat patients. This, it is estimated, resulted in over 30,000 individuals being infected with serious conditions such as HIV and Hepatitis viruses and caused more than 3000 deaths.

The Inquiry has examined both the causes of this tragedy and the devastating impact had on those “infected and affected”. Those impacted had to bear not only the physical and psychological consequences of the infections, but also the significant stigma associated with the viruses contracted, and many years of cover up, defensiveness and failures to adequately respond by those in positions of power.

The Saunders Law team led by Cyrilia Davies Knight, alongside Counsel team, Karon Monaghan KC of Matrix Chambers and Philip Dayle of No5 Chambers, represent Core Participants in the Inquiry, all of whom were infected with both HIV and Hepatitis C, following treatment for haemophilia with blood products.

The report’s key findings

Today, Sir Brian Langstaff was welcomed with a standing ovation as he delivered his seven volume report and closing remarks to the public at Central Hall Westminster.

The Inquiry’s full final report can be found here. In the report’s summary, Sir Brian powerfully states:

 “I have to report a catalogue of failures that caused this to happen. Each on its own is serious. Taken together they are a calamity. Lord Winston famously called these events “the worst treatment disaster in the history of the NHS”. I have to report that it could largely, though not entirely, have been avoided. And I have to report that it should have been.

I also have to report systemic, collective, and individual failures to deal ethically, appropriately, and quickly with the risk of infections being transmitted in blood, with infections when the risk materialised, and with the consequences for thousands of families.”

The Chair identifies “repeated failures” “by doctors, by the bodies (the NHS and other) responsible for the safety of their treatment, and by their governments”, falling under some key themes, including:

  • Slow and protracted decision-making in response to infected blood and failures to make patient safety the paramount focus of such decision-making;
  • A profoundly unethical lack of respect for individual patient autonomy – coupled with dangerous use of the principal of “clinical freedom”, which allowed doctors to follow unsafe treatment practices without interference; and
  • Institutional defensiveness, from the NHS and from government, compounded by groupthink amongst civil servants and ministers and a lack of transparency and candour – all of which exacerbated the damage done to the people whose lives had been destroyed by infection, through refusals to accept responsibility, refusal to provide answers or compensation, and a lack of any real recognition or meaningful apology.

Specifically for those infections “caused needlessly to people with bleeding disorders”, some of the key causes identified in Sir Brian’s report include:

  • Failures in the licensing regime for blood and blood products, in particular by allowing the importation and distribution of high risk blood products from the US, and continuing to allow the use of commercially sourced blood products;
  • Failure to ensure sufficient supply of Factor VIII concentrates from UK donors to meet the reasonably foreseeable demand;
  • Increasing the size of donor pools used to manufacture blood products, although it was well known that this would significantly increase the risk of viral transmission;
  • Failing to encourage and finance research into methods of viral inactivation of factor concentrates;
  • Failing to ensure sufficiently careful and rigorous donor selection and screening, and allowing continued collection of blood from prisons;
  • Adopting an attitude of denial towards the risk of treatment with factor concentrates;
  • Treating people with ever-increasing volumes of concentrates, despite the increased risks of viral transmission;
  • Failing to respond to serious risks of infection by making adjustments to treatment to make them safer, for example by making greater use of cryoprecipitate;
  • Falsely re-assuring the public and patients that blood did not carry AIDS and that the risks were low;
  • Failing to tell people of the risks of treatment and available alternative treatments, thus treating them without their informed consent;
  • Conducting research on people without telling them beforehand of informing them of the risks; and
  • In some cases, failing to tell people that they were infected and thereby denying them the opportunity to tell people they were infected.

The report’s recommendations

The report has made a number of recommendations, in particular:

  • The Chair’s principal recommendation remains that a compensation scheme should be set up now.
  • There should be a formal apology from those who are responsible for what happened, which, in order to be sincere and meaningful, should give sufficient detail of what is being apologised for, and should lead to action.
  • There should be a permanent memorial established in the UK to recognise and remember what happened to people.
  • Public health bodies should take steps to ensure that lessons that can be learned from the infected blood tragedy, which, for example, should be incorporated into every doctor’s training.
  • Steps should be taken to end the defensive culture in civil service and government.
  • There should be efforts to ensure a safety culture in healthcare, through reviews of the duty of candour, simplifying external regulation of safety in healthcare, auditing of patient records, and taking steps to change the culture of defensiveness, lack of openness and dismissiveness of concerns about patient safety.
  • All patients that contracted illness through infected blood should be provided with the necessary care.
  • Efforts should be made to identify any individuals that may still be undiagnosed.

Timeframe for the government response

Sir Brian has given the government 12 months to consider and either commit to the report’s recommendations, or give sufficient reason and detail as to why it is not considered appropriate to implement any one or more of them.

Notably, Sir Brian has stated that, while he anticipates that at that stage, he should be able to tell the Minister that the Inquiry has fulfilled its terms of reference, he will only do so if he is satisfied that there is no further role he can usefully play in preventing delay. This inclusion is significant, as it allows Sir Brian to retain powers and maintain pressure on government to respond following the publication of his report.

Saunders Law’s response to the report

The report’s conclusions and its criticisms of those responsible for contaminated blood and its repercussions are welcomed by Saunders Law and our clients.

One of Saunders’ clients, Richard, comments:

“To have a Judge, legal counsel and eventually the public believe that I was poisoned by the state with HIV and Hepatitis C rather than be dismissed by politicians and doctors as a fantasist or conspiracy theorist is one of the most powerful things to happen to me.

I’d like to thank Sir Brian, Jenni Richards KC and all the team at the Inquiry for giving us a safe space to tell our stories, however harrowing it has been. 

To those innumerable doctors, politicians and civil servants who ignored me for forty years I say, read this report and weep, not for me but for your consciences. 

I feel a tremendous relief at being heard at last and would also like to thank the fantastic team at Saunders, including our Counsel, Karon and Philip, for their unwavering support over the years.

Lastly, this report is for the friends we have lost through this tragic event and all those who didn’t live to see this day.”

Additionally, another of Saunders’ clients, Paul, says:

“The Inquiry team and my legal team have handled this exceptionally, and I feel lucky to have had the support and representation that I have experienced… After this report I feel that I will be able to accept closure and hope that the truth of our infections, the way we were treated, the cover ups by successive governments, and the media mistruths will be clear to all… Our struggles for the truth and justice, for the infected, affected and deceased will soon be over. I only hope that our suffering can change the political landscape for future patients worldwide.”

Cyrilia Davies Knight, Partner at Saunders Law notes:

“This damning report is a stunning vindication of my clients’ 4 decades long quest for justice. I can only hope that this report marks a significant turning point in obtaining some measure of closure for this utterly preventable catastrophe. Going forward, we hope that the government considers carefully the learning points from this disaster and wastes no time to implement Sir Brian’s recommendations.”

Our lawyers at Saunders law are experts in Public Inquiries and actions against public authorities. For advice about a Public Inquiry, or making a claim against the state, please contact us on 020 7632 4300 to discuss your concerns.


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