Rishi Sunak has apologised to the victims of the biggest treatment disaster in NHS history, declaring that it should “shame our nation to its core”.
Tens of thousands of people in the UK were infected with deadly viruses after they were given contaminated blood and blood products between the 1970s and early 1990s.
The final report of the Infected Blood Inquiry, published on Monday, found there has been “deliberate destruction” of relevant documents and “elements of downright deception” from those in positions of trust and power.
And the Prime Minister has vowed to pay “comprehensive compensation” to those affected by the scandal, “whatever it costs”.
He told MPs: “This is a day of shame for the British state.
“Today’s report shows decades long moral failure at the heart of our national life. From the National Health Service, to the Civil Service, to ministers and successive Governments.
“At every level, the people, and institutions in which we place our trust, failed in the most harrowing and devastating way.
“They failed the victims and their families.
“And they failed this country. Sir Brian finds a catalogue of systemic collective, and individual failings. Each, on its own serious, and taken together, amounting to a calamity.
“The result of this inquiry should shame our nation to its core.
“This should have been avoided. It was known these treatments were contaminated, warnings were ignored repeatedly.”
The Prime Minister said he was “truly sorry” for the “layer upon layer of hurt endured across decades”.
He said, in a statement to Parliament: “I want to make a whole-hearted and unequivocal apology for this terrible injustice.
“First to apologies for the failure in blood policy and blood products, and the devastating and so often fatal impact its had on so many lives, including the impact of testaments that were known or proved to be contaminated, the failure to respond to the risk of imported concentrates, the failure to prioritise self-sufficiency in blood, the failure to introduce screening services sooner, and the mismanagement of the response to the emergence of Aids and hepatitis viruses amongst infected blood victims.
“Second to apologise for the repeated failure of the state and our medical professionals to recognise the harm caused. This includes the failure of previous payment schemes, the inadequate levels of funding made available and the failure to recognise hepatitis B victims.
“And third, to apologise for the institutional refusal to face up to these failings and worse to deny and even attempt to cover them up.”
Mr Sunak told MPs that “time and again people in positions of power” failed.
The Prime Minister said: “People in positions of power and trust had the chance to stop the transmission of those infections. Time and again they failed to do so.
“Sir Brian finds an attitude of denial towards the risks of treatment.
“Worse, to our eternal shame in a way that it is hard to even comprehend, they allowed victims to become objects for research.”
Chairman of the inquiry, Sir Brian Langstaff, said in the report: “Standing back, and viewing the response of the NHS and of government overall, the answer to the question ‘was there a cover-up’ is that there has been.
“Not in the sense of a handful of people plotting in an orchestrated conspiracy to mislead, but in a way that was more subtle, more pervasive and more chilling in its implications.
“In this way there has been a hiding of much of the truth.”
According to the report, there was a deliberate decision to destroy Department of Health files which contained material dealing with delays in the introduction of screening blood donations for hepatitis C.
The files, which related to decision-making of the Advisory Committee on the Virological Safety of Blood (ACVSB), were marked for destruction in 1993.
“The destruction was not an accident, nor the result of flood, fire or vermin,” Sir Brian wrote.
“The immediate reason for destruction was human choice. Someone, for some reason, had chosen to have those documents destroyed.”
He said: “It is an uncomfortable conclusion that it is more likely than not that a civil servant chose to destroy the documents because they were those documents: but if that is what the evidence amounts to, it is the conclusion that must follow.”
Sir Brian continued: “In short, it is on this basis more likely than not that the authorisation to destroy the (ACVSB) files was because the documents contained material dealing with delays in the UK to the introduction of screening of blood donations for hepatitis C, which was anticipated (or known) to be a live issue at the time.
“If this is right, it was a deliberate attempt to make the truth more difficult to reveal.”
He added that any conclusion “bound to be tentative” and that it is “almost certain that it was not orchestrated ‘from the top”‘.
In his address to attendees on Monday, Sir Brian said campaigners had at points “pieced together a much fuller understanding of what had happened than the Department of Health”, despite the “challenges of ill-health and grief”.
The inquiry’s final report also explored the destruction and disappearance of medical records from hospitals, GPs and health boards.
It told of the “emotional toll” people went through trying to obtain records, making reference to a woman who described trying to get her late father’s medical records as “like a battle of wills”.
The report concluded that it is likely records went missing because of a “mixture of incompetence, a lack of proper systems, and the problems inherent in keeping paper records”.
“That said, the possibility that there may have been occasions in the past when records may deliberately have been left incomplete or have been filleted remains,” Sir Brian wrote.
He said there are “reasons for concern”, but it is not possible to reach firm conclusions.
“Although there is suspicion that some health authorities or individuals reacted in a similar manner to what was happening around them, by hiding, removing or destroying some records that might be an embarrassment, there is insufficient evidence to conclude that a finding to this effect is justified across the board,” the chairman said.
The lack of medical records has made it difficult for some to apply for compensation.
“In the case of some documents, it is simply not possible now to know how and why they went missing – for others, I have concluded that they were deliberately and wrongly destroyed in an attempt to make the truth more difficult to reveal,” Sir Brian said on Monday.
He added that “poor record keeping” impacted safety.
“If you can’t trace the source of a transfusion back to the donor who was infected, you cannot then tell and treat the donor, and avoid any further donations from that source,” the inquiry chairman said.
“Nor can you trace previous donations to check if other people who have had transfusions from the same source have become ill.”
Campaigners said references in the report to cover-ups were “no surprise” with Andy Evans, chair of Tainted Blood, telling a press conference: “We have been gaslit for generations.”
Rosamund Cooper, who found out she had been infected with hepatitis C when she was 19, called the cover-ups and denials “disgraceful”.
“It’s showing that that’s not the case, and that people were covering things up, denying things, hiding things from us, which is disgraceful. That never needs to happen again,” she told the PA news agency.
