UK infected blood inquiry: key findings

Sir Brian Langstaff’s softly spoken manner has been a hallmark of his six-year inquiry into the UK’s infected blood scandal.

But on Monday, the former High Court judge was scathing in his long-awaited report into how 30,000 people in the UK contracted HIV, hepatitis C and other diseases through contaminated blood products between the 1970s and early 1990s.

Langstaff found “systemic, collective and individual failures” by government departments and various parts of the NHS led to a “calamity” that has so far claimed more than 3,000 lives and “destroyed friendships, families [and] finances”. 

These are four key findings from the 2,527 page report.

Experiments on children

Children with the rare blood condition haemophilia were used as “objects for research” while attending a specialist boarding school.  

Clinicians at the NHS haemophilia centre on the school grounds of Treloar’s in Hampshire, southern England, treated children without their consent.

Evidence showed health officials working at the school were “well aware” that their programme of treatment risked causing Aids, Langstaff said.

Yet a programme of medical research was carried out “to an extent which appears unparalleled elsewhere”, he found.

“Very few escaped being infected” with either hepatitis or HIV after receiving blood plasma products from doctors who favoured the “advancement of research” over the children’s wellbeing.

Just 30 of the 122 pupils with haemophilia who attended the school between 1970 and 1987 have survived to this day.

Political cover-up

Langstaff accused both government and health officials of “downright deception”, including destroying documents to “save face and save expense”.

Three sets of key government documents in the 1980s and 1990s were lost or destroyed, relating to HIV litigation, the work of a blood safety advisory committee and the private papers of the former minister Lord David Owen.

Certain files were “deliberately destroyed”, Langstaff found, concluding that this was because the documents may reflect badly on the government as they “contained material dealing with delays in the UK to the introduction of screening blood donations for hepatitis C”.

It was not clear who had taken the decision to destroy them. Langstaff said there was no evidence of “impropriety” to suggest Owen’s papers were destroyed because of the contents, rather than what was believed at the time to be “appropriate procedure”.

Individual patient medical records after certain procedures involving contaminated products were also destroyed, he said.

Langstaff also said the credo of “‘Doctor knows best’ was such a strong belief” in Whitehall that no guidance was issued to the NHS “to curb unsafe use of blood and blood products”.

In February 1980, the then Department for Health and Social Security acknowledged in a note the higher rates of infection from blood donated by people in high-risk groups, such as prisoners. An advisory group began meeting 10 months later, but “no action was taken”. 

As far back as 1982, Harold Gunson, consultant adviser to the chief medical officer, warned civil servants of the possibility of Aids being transmitted through blood.

The UK infectious disease expert Dr Spence Galbraith wrote to the health department calling for imports of US blood products to be halted.

The department’s response, Langstaff said, was “wholly inadequate”, noting that officials did not bring it to the attention of ministers or the chief medical officer. 

Imported blood plasma treatments

Needless suffering and illness was caused by a failure to ensure the UK had its own supply of blood plasma treatments for those suffering with haemophilia until as late as 1990.

Instead, the NHS imported the blood clot plasma treatment known as Factor VIII from the US, which carried a high risk of causing hepatitis, and was understood to be “less safe” than UK treatments for bleeding disorders.

There was an “attitude of denial” towards the risks of these treatments, Langstaff said. “These products should simply not have been permitted to be distributed generally in this country.”

He added that this failure to achieve “self-sufficiency” was because of an “inept, fragmented system” of blood services operating in England and Wales.

Unnecessary blood transfusions 

Doctors authorised contaminated blood transfusions that were not medically required, especially for women after childbirth.

Healthcare staff wrongly assumed that the blood treatments posed little or no risk to patients, Langstaff said, adding that there had been a lack of proper record keeping when these procedures were “used unnecessarily”.

Between 80 and 100 people were infected with HIV after a blood transfusion, while 26,800 were infected with hepatitis C.

“It appears that there was a level of complacency about the safety of blood resulting in measures not being taken earlier throughout the UK to improve the overall safety,” Langstaff said. “It is clear had such measures been taken earlier, it is likely that lives would have been saved.”