The 2,527 pages of Sir Brian Langstaff’s report make for deeply uncomfortable and difficult reading.
He warns in the summary to his damning document: “It will be astonishing to anyone who reads this report that these events could have happened in the UK.
“The wrongs were done on individual, collective and systemic levels.”
For the victims and the families of the infected and affected by this scandal, this report is an absolute vindication of everything they have been saying for the last 40 or so years.
Patients – including many young children – were involved in secret trials and experiments, the clinicians involved knew about the risks, and when strong evidence began to emerge concerns were dismissed.
Families were continually gaslighted with a “doctor knows best” response.
This was at the beginning of the scandal, but what followed was decades of denial, with successive governments refusing to establish a public inquiry to avoid compensation payments.
Campaigners have been saying for years they are the victims of a cover-up. Nobody listened or took those claims seriously.
But now Sir Brian says the destruction of documents was “hiding the truth”.
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The Treloars school, rightly, earns its own mention in this report.
A specialist school that was supposed to treat haemophilic children instead became a laboratory where experiments could be carried out on children without them or their parents knowing.
Only 30 of 122 pupils with haemophilia who attended the school between 1970 and 1987 are still alive.
Dr Rosemary Biggs, one of the lead clinicians at the site at the time, is quoted as saying: “The collection of 49 haemophiliac patients at the school makes this a unique opportunity to study this disease.”
Sir Brian says: “The pupils were regarded as objects of research rather than children.”
He adds this was both “unethical” and “wrong”.
The report concludes by saying this scandal could and should have been avoided. The victims and their families have been saying this all along.
Sir Brian Langstaff’s report has found they were right.
A workman saved a seven-year-old boy from a burning car in the aftermath of a deadly crash caused by a suicidal ex-pilot, an inquest has heard.
The schoolboy’s rescue came following the collision on the M6, which killed former RAF man Richard Woods and four others, in October last year.
Last week a coroner ruled that Woods, 40, took his own life by deliberately driving his Skoda the wrong way down the motorway while drunk and hitting a Toyota Yaris head-on.
The driver of the Toyota, Jaroslaw Rossa, 42, was also killed, along with his two sons, Filip, 15, and Dominic, seven, and his partner Jade McEnroe, 33.
Cockermouth Coroner’s Court heard on Thursday that Ms McEnroe’s son was also in the car but survived after workman Gavin Walsh came to his rescue at the scene, which was near Tebay services in Cumbria.
In a statement to the inquest, Mr Walsh said he was a passenger in a transit van travelling to Scotland when he witnessed the crash.
He jumped out of the vehicle and used a jack to smash the rear windscreen of the Toyota and pulled the boy out of the burning vehicle.
Mr Walsh said: “We really did try, I can assure everyone we did our best. We only had minimal time.
“I saved a life that day and I hope never to witness anything like that again.”
He added that he has never stopped thinking about the boy, and said: “I hope we will meet again one day and I will give you a massive hug.”
At the time, the family were returning to Glasgow from a trip to Legoland in Windsor, Berkshire.
The inquest heard that Wood, who was travelling at a speed of at least 65mph, would have been charged with manslaughter had he survived.
Recording conclusions of unlawful killing, Cumbria assistant coroner Margaret Taylor said: “I found that Jaroslaw, Jade, Filip and Dominic died as a consequence of the unlawful acts of another driver.”
The inquest heard how Mr Woods, from Cambridgeshire, had served a distinguished 14-year career in the RAF and was a flight instructor for BAE Systems at the time of his death.
Image: Jade McEnroe. Pic: Cumbria Constabulary
Image: Dominic and Filip. Pic: Cumbria Constabulary
In Ms Taylor’s record of inquest, Mr Woods was said to have been experiencing “a number of stressors in his life” and had a “history of harmful use of alcohol”.
Following the crash, he was found to be nearly four times over the legal drink-drive limit and a two-thirds empty bottle of gin was found in his car.
On the day of his death, concerns had been raised over his behaviour at a work conference near Preston in Lancashire.
Mr Woods failed to return to his seat after lunch and was later spotted driving erratically and swerving across three northbound carriageway lanes on the M6.
After pulling onto the hard shoulder, he then proceeded to U-turn and drove southward on lane three.
Image: Filip, Dominic and Jaroslaw Rossa. Pic: Cumbria Constabulary
Detective Sergeant Deborah Story, from Cumbria Police, told the inquest that Mr Woods would have been prosecuted on four counts of manslaughter had he lived.
She said hypothetical charges of murder were considered by detectives but not thought appropriate because of a lack of information that Mr Woods knew the family or anything that provided a link between them.
Ms McEnroe’s parents, Marie McEnroe and George McNellis, told the coroner they thought it was “murder”.
A statement from the mother of Filip and Dominic, and the ex-wife of Mr Rossa, Kamila, was read out at the inquest.
She said Mr Rossa, known as Jarek, was born in Poland where they became a couple and went on to have three boys.
He loved playing computer games and had “lots of friends”, she said, and worked at the Wagamama restaurant in Silverburn, Glasgow.
She said she was “devastated” over the deaths, adding: “Our lives will never be the same.
“I am heartbroken at the passing of my beloved angels Filip and Dominic.”
Marie McEnroe said her daughter, a spa therapist, had been in a relationship with Mr Rossa for about two-and-a-half years.
She said Jade had been a “brilliant mother” to her only child, was “really happy” with Mr Rossa and it was “lovely chaos” when all the boys were playing together.
Ms McEnroe added: “Life changed forever that day”.
Ms Taylor praised the “selfless acts of bravery” from those in the aftermath of the collision, including Mr Walsh, who she said went towards the burning car “without hesitation for his own safety”.
The coroner added: “Without his swift response, Jade’s child would also have perished.”
Addressing the bereaved family members, she said: “Your loss is unimaginable but you have conducted yourself with dignity and I thank you for that. I wish you strength for the future.”
Anyone feeling emotionally distressed or suicidal can call Samaritans for help on 116 123 or email jo@samaritans.org in the UK. In the US, call the Samaritans branch in your area or 1 (800) 273-TALK.
A ‘vile’ former police officer who was caught in a sting operation after travelling to meet what he thought was a 14-year-old boy has been jailed.
Thomas Kettleborough, 35, then an inspector with Avon and Somerset Police, was arrested in July 2023 while attempting to meet up with ‘the teenager’ after communicating with him on Grindr and Snapchat.
However, he was actually speaking to undercover officers.
After being detained at a car park in Bristol, officers found a bag in the boot of his car containing “an assortment of sex toys, condoms and bondage equipment, including a pair of limb restraints,” Exeter Crown Court heard.
More than 150 indecent images of children were also discovered on his phone and computer.
Kettleborough used the apps to have sexually explicit chats with the teenager, using the name Liam, while claiming to be 28, prosecutors said.
In February, he pleaded guilty to several child sex offences, including attempting to engage in sexual communication with a child and attempting to cause or incite a child to engage in sexual activity.
Last month he was sacked by Avon and Somerset Police and barred from policing for gross misconduct.
He was sentenced to two years and eight months in prison on Thursday.
Assistant Chief Constable Joanne Hall, from Avon and Somerset Police, said the public would be “appalled by the vile and manipulative actions of this former officer”.
She added: “He was caught following a policing operation designed to keep children safe which has resulted in his wider offending being identified.”
Detective Inspector Dave Wells, who led the investigation, said Kettleborough’s crimes took place over four years,
The former officer held positions of trust in the police, the Sea Cadets and the Royal Lifesaving Society, but “concealed his true identity through an online persona as ‘Liam’, ‘L S’ and ‘Liamss5506’,” Mr Wells said.
Mr Wells added: “Specialist investigators are ready to listen and investigate any reports relating to Thomas Kettleborough or any other matters of concern. I want people to know that they will be believed.
“Thomas Kettleborough is now behind bars. I hope if there are others that have been affected by this case, they now feel empowered to tell someone, if they are ready to do so.”
Lee Bremridge, defending, said Kettleborough had shown genuine remorse for his crimes.
He added that the former officer had “done everything that he can attempt to do to try and understand why it is he committed the offences that he did.”
Kettleborough was also handed an indefinite Sexual Harm Prevention Order and will be on the Sex Offenders’ Register for life.