Infected blood scandal: Who is to blame for the 'biggest treatment disaster' in NHS history?

The prime minister has said it is a 'day of shame' for the British state. But will anyone be held to account for what happened? ITV News Political Correspondent Carl Dinnen reports


The lives of more than 30,000 people in the UK were upended after they were infected with diseases linked to contaminated blood products during the 1970s and 1980s.

The diseases - Hepatitis C and HIV - resulted in the deaths of around 3,000 patients - 380 of which were children.

On Monday, a seven-year public inquiry published its final report, which it said will provide a measure of justice to the thousands of people affected in what has been called the "biggest treatment disaster in NHS history".

According to the report, the patients had been failed "not once, but repeatedly" by doctors, the government, the NHS, and others.

ITV News outlines who exactly was responsible for the disaster, and whether or not they will face consequences.

NHS and doctors

The risks of blood and blood products causing severe infection were "known well before most patients were treated," the report found.

Yet, patients were not informed of the risks or the alternatives, with a culture of "doctor knows best" prevailing among the ranks of the NHS.

In some cases, patients were not even told they had been infected, whilst others were informed, but in ways that were “insensitive and inappropriate,” the report found.

Haematologists of the era have been also heavily criticised, including leading haematologist, Professor Arthur Bloom, whose opinions "disastrously" influenced the UK Department for Health and Social Security (DHSS), the report said.

According to the report, Prof Bloom failed to pass on warnings and advised to continue importing commercial factor concentrates.

Sir Brian Langstaff, inquiry chair, said Prof Bloom - who died in 1992 - "must bear some of the responsibility for the UK's slowness in responding to the risks of Aids to people with haemophilia".

At the time, Prof Bloom said he was unaware of any proven case in the UK and that there was no need to change treatment.

Survivors of the infected blood scandal who were students at Treloar's College, in Hampshire. Credit: PA

Treloar College

Some of the worst mistakes of the scandal were made at Lord Mayor Treloar College, in Alton, Hampshire, between the 1970s and 1980s.

Several of the male pupils who attended the boarding school at the time were given treatment for haemophilia at an on-site NHS centre while receiving their education.

It was later found that many pupils with the condition had been treated with plasma blood products which were infected with Hepatitis C and HIV. More than half of the students treated are now dead.

School administrators were not blamed in the report, but NHS clinicians who treated boarding school pupils on the grounds were.

According to the inquiry, the clinicians were "well aware" of the risks of infecting the children, which it says were regarded as "objects of research".

A statement released by the college on Monday said the inquiry "lays bare the systemic failure at the heart of the scandal".

The statement continued: "Whilst today is about understanding how and why people were given infected blood products in the 1970s and 80s, it is absolutely right that the government has committed to establishing a proper compensation scheme.

"We’ll now be taking the time to reflect on the report’s wider recommendations."

Des Collins, a lawyer who is representing the 1,500 clients from the college called for a criminal prosecution, and said his clients had been "waiting a long time" for justice.

"They don't have it in them to wait any longer," he added.


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Ministers

Former and current politicians were criticised by the inquiry’s report for a failure to act on concerns about infected product supply, to make the UK self-sufficient in blood product supply, for neglecting to give victims justice and compensation earlier, and for orchestrating a cover-up.

Among them is former prime minister Margaret Thatcher, who reportedly said in a 1989 Downing Street meeting that people infected with HIV from blood products "had been given the best treatment available on the then current medical advice, and without it many hemophiliacs would have died".

The report called the statement a "blanket line" that was "inappropriate" and "unacceptable".

Ms Thatcher never apologised for the scandal before her death in 2013 despite mounting evidence.

Margaret Thatcher asserted in 1989 that people infected with HIV from contaminated blood had been 'given the best treatment available'. Credit: PA

When asked by victim groups for compensation in 1990, Ms Thatcher responded in a letter: "The government has not accepted that the infection of haemophiliacs with the Aids virus, tragic as it is, was the subject of negligence."

She also said the blood scandal victims receiving compensation would be "unfair" to other disabled people. Other ministers echoed these words in successive years.

Another person mentioned in the report was Kenneth Clarke, health minister at the time, who was quoted writing in an 1983 Aids leaflet that there is "no conclusive proof" that Aids "may be transmitted in blood or blood products".

Mr Clarke was also accused in the report of "lacking curiosity" to find out more about the scandal and hold those responsible accountable.

Former prime minister Theresa May. Credit: PA

The report is critical of decisions taken by him when he was health minister.

It says: "On 25 February 1985, Kenneth Clarke, minister of state for health, stated, 'There has never been a general state scheme to compensate those who suffer the unavoidable adverse effects which can unhappily arise from many medical procedures'... It set the tone for the government’s response for many years."

The report was also critical of the delays to calling a public inquiry - blaming the then-prime minister Theresa May for only announcing it in 2017 due to political pressure.

Sir Brian said the fact it took so long has hampered his investigation as key people have since died or have been too frail to give evidence.

Will there be criminal inquiries?

The inquiry process has no scope to determine civil or criminal liability.

Whether any prosecutions actually happen remains to be seen, and could involve yet another long wait for those affected.

Corporate manslaughter, in particular, is a complex offence to prosecute. Since it was introduced in 2008, there have been only a few dozen cases, with a handful involving the NHS.


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