A “catalogue of failures” by government officials and doctors in Britain, most of them avoidable mistakes, has led to blood contamination that has killed around 3,000 people and infected more than 30,000 over two decades, according to a long-awaited report released Monday.
The report is the product of a six-year investigation ordered by the British government in 2017 after decades of pressure from victims and their families, and could pave the way for large compensation payments.
Independent report puts spotlight on Britain's state-run National Health Service, identifying “systemic, collective and individual failures” by British authorities to manage infections of tens of thousands of people caused by transfusions of contaminated blood or blood products contaminated between the 70s and 90s.
Authorities at the time refused to acknowledge these shortcomings – including a lack of adequate screening and blood tests – “hiding the truth,” the report said.
“This disaster was not an accident,” Brian Langstaff, a former High Court judge who led the inquiry, said at a news conference on Monday. “People put their trust in doctors and the government to keep them safe, and that trust has been betrayed.”
He added: “The NHS and successive governments have compounded the agony by refusing to accept that a wrong had been done.”
In the summary of the 2,000-page report, Langstaff wrote that the investigation had documented a “catalogue of failures.”
“Each in itself is serious,” he wrote. “Taken together they are a calamity.” According to him, the problems “could have largely, although not entirely, been avoided”.
At a press conference in London, blood contamination victims and their families expressed relief at the report's findings, but also anger that it had taken so long. They said it was now up to the British government to recognize its failures and adequately compensate victims.
Andy Evans, a longtime activist who was 13 when he discovered that a blood transfusion for his hemophilia had given him HIV, said he felt “validated and vindicated.”
“We have been enlightened for generations,” Mr. Evans said. “This report puts an end to that.”
British Prime Minister Rishi Sunak is expected to make an official government apology to Parliament on Monday for the failures, many of which occurred before Sunak was even born. The British government had agreed in 2022 to distribute an interim payment of 100,000 pounds, or about $127,000, to each victim.
The inquiry had no authority to recommend criminal prosecutions and it was not immediately clear whether the report would lead to any.
“If there is clear evidence and there is a path towards that, then it is obviously something that the government will have to address,” John Glen, the British government official responsible for matters relating to the contaminated blood investigation, told LBC radio. Monday.
“I can't be sure, but we need to give these people justice,” Glen said.
The scandal has its roots in the 1970s and 1980s, when thousands of patients were exposed to contaminated blood. Some have needed blood transfusions after accidents, surgeries or complications during childbirth, but their transfusions were not screened for HIV or hepatitis C.
Many others were patients with hemophilia, a genetic condition that prevents blood from clotting properly. At the time, many of them were given a blood plasma-derived treatment called Factor VIII that provided the missing protein that hemophiliacs need for blood clotting.
The treatment was carried out using plasma pools from thousands of donors, meaning that even a small number of contaminated donations could contaminate an entire pool. (Synthetic clotting factor proteins were later developed.)
The NHS imported some factor VIII from the United States, where many donations came from prisoners or drug users who had been paid to donate blood, increasing the risk of HIV or hepatitis C contamination.
Campaigners who pushed for the inquiry say British authorities failed to heed warning signs about the lack of screening and risks associated with using blood products imported from the United States.
The commission of inquiry – made up of legal professionals, investigators and public officials – listened to infected people, their relatives and loved ones; medical and ethical experts; government officials and politicians.
Previous investigations and offers of compensation had been deemed insufficient by victims and their families. In 2009, an independent report concluded that the tragedy could have been avoided if blood imports from the United States had been stopped, but it did not blame individual doctors or companies, and no one from the Department of Health was called to testify.
In 2015, an investigation in Scotland prompted an apology from David Cameron, the then prime minister, but was deemed unsatisfactory by victims and their families because it was unable to call witnesses from outside Scotland.
Other nations, including the United States and Japan, have faced similar scandals. In France, several senior health officials were convicted in 1992 on charges of distributing contaminated blood, and France's then-health minister was convicted in 1999 of negligence. But he received no punishment and two other senior officials, including Laurent Fabius, the then prime minister, were acquitted.