An inquiry into the infected blood scandal has pointed the finger at several people and organisations after more than 30,000 patients were “knowingly” infected with HIV or Hepatitis C.
Inquiry chair Sir Brian Langstaff said the “disaster was not an accident” and there was a “catalogue of failures” and a “pervasive” cover-up by the NHS and successive governments.
More than 30,000 Britons were infected with HIV and Hepatitis C after being given contaminated blood products in the 1970s and 1980s.
About 3,000 people died as a result, while many more still live under the shadow of health problems, debilitating treatments and stigma.
Speaking after the report was published on Monday following the seven-year inquiry, Sir Brian said: “The damage caused was compounded by the reaction of successive governments, the NHS and the medical profession.
“Successive governments refused to admit responsibility to save face and expense.
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“Today’s report also found that the response to the infections made things worse, including repeated failures by governments and the NHS to acknowledge the victims should not have been infected in the first place.”
In the report, he named specific people and institutions in his criticism.
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They included:
Lord Clarke
Kenneth Clarke, now a lord, was heavily criticised by Sir Brian.
He was a health minister in Margaret Thatcher’s government from 1982 to 1985, then health secretary from 1988 to 1990.
Image: Ken Clarke was later John Major’s chancellor. Pic: PA
Lord Clarke was accused of being “somewhat blasé” when he gave evidence to the inquiry about the collection of blood from prisoners as late as 1983.
His manner was described as “argumentative”, “unfairly dismissive” and “disparaging” towards those who have suffered, with Sir Brian saying he played “some part” in that suffering.
The report said it was “regrettable that he could not moderate his natural combative style in expressing views”.
Image: Inquiry chairman Sir Brian Langstaff with victims and campaigners. Pic: PA
The Thatcher government
Margaret Thatcher, as well as subsequent governments and health secretaries, continually said infections were “inadvertent” and patients were given “the best treatment available on the then current medical advice”.
The inquiry report concluded that was not true and said the factual basis for the claim was unclear.
“In short, adopting the line amounted to blindness,” the report said.
“Adopting it without realising it needed to have a proper evidential base, and they did not know what it was, was unacceptable.
“The line, which was wrong from the very outset, then became entrenched for around 20 years: a dogma became a mantra.
“It was enshrined. It was never questioned.”
Image: Margaret Thatcher. Pic: PA
Sir Brian added that the Thatcher government “did not respond appropriately, urgently and proactively” to the risks of Hepatitis C and HIV transmissions through blood.
He said the government knew there was a much higher incidence of Hepatitis in prisoners, yet “no action” was taken to stop blood donations from them, which “increased the risk of transmission”.
The failure lied “principally at the door” of the health departments in Westminster and Scotland, he said.
He said the Thatcher government signed up to recommendations in 1983 from the Council of Europe to inform clinicians and patients about the risks of treatment – yet failed to follow those recommendations.
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Infected blood scandal ‘no accident’
Sir Brian described the failure to provide any guidance to doctors about the risk of transmission of AIDS as “inexcusable”.
On compensation, he also said the Thatcher government “plainly formed the view, at an early stage, that nothing had been done wrong, and that no financial assistance would be provided to people with bleeding disorders who had been infected with HIV”.
He added: “It did so without any proper investigation either into what had caused the infections or into the appalling plight of those infected.”
Treloar School
Haemophiliac children were sent to the Hampshire school with an on-site NHS clinic so they could live as near a normal childhood as possible.
Instead, 75 boys died of AIDs and Hepatitis – and 58 were infected but survived – as they were included in secret trials to test a blood product called Factor 8, which was made with blood farmed from prisoners, sex workers and drug addicts in America.
The report said there “is no doubt” the risks of virus transmission were well known to doctors at Treloar School, yet doctors “played down the risks”.
Image: Treloar students from the 1970s and 1980s at the inquiry. Pic: PA
Some pupils and parents were “never informed” by the school the boys had tested positive for HIV, which Sir Brian said “was unconscionable”.
Treloar School was a “microcosm” of much of “what went wrong in the way haemophilia clinicians treated their patients across the UK,” he added.
The school said in a statement: “We are devastated that some of our former pupils were so tragically affected and hope that the findings provide some solace for them and their families.”
It added that its management was “absolutely committed to exploring” calls for a public memorial to those affected, and added: “We’ll now be taking the time to reflect on the report’s wider recommendations.”
Alder Hey Children’s Hospital
The hospital was the main site in Liverpool for children with bleeding disorders from the late 1970s onwards.
Doctors used Factor 8 concentrate containing contaminated blood to treat them, even after other haemophilia centres stopped using them on children, Sir Brian found.
Alder Hey’s director from the mid-1970s, Dr John Martin, “did not regard the risk of Hepatitis as a reason to alter any treatment regime”, the report added.
“He exposed them to wholly unnecessary risks,” it said.
Sky News has approached Alder Hey for comment.
Image: Alder Hey Children’s Hospital in Liverpool. Pic: PA
Sir Brian Langstaff said he “must bear some of the responsibility for the UK’s slowness in responding to the risks of AIDs to people with haemophilia”.
Prof Bloom said at the time he was unaware of any proof linking infections to the blood products and said there was no need to change patients’ treatment, Sir Brian said.
He added: “Disastrously the Department of Health and Social Security was over-influenced by his advice, in particular his advice to continue importing commercial factor concentrates.”
Image: Professor Arthur Bloom
The NHS
Sir Brian said the response of the NHS and the government showed there was not a major plot to cover up failures “in an orchestrated conspiracy to mislead”.
“But in a way that was more subtle, more pervasive and more chilling in its implications,” he said.
“To save face and to save expense, there has been a hiding of much of the truth.”
He also found patients were knowingly exposed to unacceptable risks of infection, with transfusions frequently given when not clinically needed.
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‘Day of shame for the British state’
The report also said there was no contact tracing exercise carried out when Hepatitis C screenings were introduced.
Sir Brian also said the NHS and governments repeatedly failed to acknowledge people should not have been infected, despite the scandal being known about.
Prime Minister Rishi Sunak on Monday offered a “wholehearted and unequivocal” apology to victims and said it was a “day of shame for the British state”.
He said the findings of the inquiry should “shake our nation to its core” and promised to pay “comprehensive compensation to those infected and those affected.”
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4:41
Labour: ‘There was systemic failure’
The NHS said in a statement on its website: “Since September 1991, all blood donated in the UK is screened using very rigorous safety standards and testing to protect both donors and patients.
“Since screening was introduced, the risk of getting an infection from a blood transfusion or blood products is very low.”
Heathrow Airport bosses had been warned of a potential substation failures less than a week before a major power outage closed the airport for a day, a committee of MPs has heard.
The chief executive of Heathrow Airline Operators’ Committee Nigel Wicking told MPs of the Transport Committee he raised issues about resilience on 15 March after cable and wiring took out lights on a runway.
A fire at an electricity substation in west London meant the power supply was disrupted to Europe’s largest airport for a day – causing travel chaos for around 200,000 passengers.
“I’d actually warned Heathrow of concerns that we had with regard to the substations and my concern was resilience”, Mr Wicking said.
“So the first occasion was to team Heathrow director on the 15th of the month of March. And then I also spoke to the chief operating officer and chief customer officer two days before regarding this concern.
“And it was following a number of, a couple of incidents of, unfortunately, theft, of wire and cable around some of the power supply that on one of those occasions, took out the lights on the runway for a period of time. That obviously made me concerned.”
Mr Wicking also said he believed Heathrow’s Terminal 5 could have been ready to receive repatriation flights by “late morning” on the day of the closure, and that “there was opportunity also to get flights out”.
However, Heathrow chief executive Thomas Woldbye said keeping the airport open during last month’s power outage would have been “disastrous”.
There was a risk of having “literally tens of thousands of people stranded in the airport, where we have nowhere to put them”, Mr Woldbye said.
This breaking news story is being updated and more details will be published shortly.
Another 23 female potential victims have reported that they may have been raped by Zhenhao Zou – the Chinese PhD student detectives believe may be one of the country’s most prolific sex offenders.
The Metropolitan Police launched an international appeal after Zou, 28, was convicted of drugging and raping 10 women following a trial at the Inner London Crown Court last month.
Detectives have not confirmed whether the 23 people who have come forward add to their estimates that more than 50 other women worldwide may have been targeted by the University College London student.
Metropolitan Police commander Kevin Southworth said: “We have victims reaching out to us from different parts of the globe.
“At the moment, the primary places where we believe offending may have occurred at this time appears to be both in England, here in London, and over in China.”
Image: Metropolitan Police commander Kevin Southworth
Zou lived in a student flat in Woburn Place, near Russell Square in central London, and later in a flat in the Uncle building in Churchyard Row in Elephant and Castle, south London.
He had also been a student at Queen’s University Belfast, where he studied mechanical engineering from 2017 until 2019. Police say they have not had any reports from Belfast but added they were “open-minded about that”.
“Given how active and prolific Zou appears to have been with his awful offending, there is every prospect that he could have offended anywhere in the world,” Mr Southworth said.
“We wouldn’t want anyone to write off the fact they may have been a victim of his behaviour simply by virtue of the fact that you are from a certain place.
“The bottom line is, if you think you may have been affected by Zhenhao Zou or someone you know may have been, please don’t hold back. Please make contact with us.”
Image: Pic: Met Police
Zou used hidden or handheld cameras to record his attacks, and kept the footage and often the women’s belongings as souvenirs.
He targeted young, Chinese women, inviting them to his flat for drinks or to study, before drugging and assaulting them.
Zou was convicted of 11 counts of rape, with two of the offences relating to one victim, as well as three counts of voyeurism, 10 counts of possession of an extreme pornographic image, one count of false imprisonment and three counts of possession of a controlled drug with intent to commit a sexual offence, namely butanediol.
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Moment police arrest rapist student
Mr Southworth said: “Of those 10 victims, several were not identified so as we could be sure exactly where in the world they were, but their cases, nevertheless, were sufficient to see convictions at court.
“There were also, at the time, 50 videos that were identified of further potential female victims of Zhenhao Zou’s awful crimes.
“We are still working to identify all of those women in those videos.
“We have now, thankfully, had 23 victim survivors come forward through the appeal that we’ve conducted, some of whom may be identical with some of the females that we saw in those videos, some of whom may even turn out to be from the original indicted cases.”
Mr Southworth added: “Ultimately, now it’s the investigation team’s job to professionally pick our way through those individual pieces of evidence, those individual victims’ stories, to see if we can identify who may have been a victim, when and where, so then we can bring Zou to justice for the full extent of his crimes.”
Mr Southworth said more resources will be put into the investigation, and that detectives are looking to understand “what may have happened without wishing to revisit the trauma, but in a way that enables [the potential victims] to give evidence in the best possible way.”
The Metropolitan Police is appealing to anyone who thinks they may have been targeted by Zou to contact the force either by emailing survivors@met.police.uk, or via the major incident public portal on the force’s website.
An 11-year-old girl who went missing after entering the River Thames has been named as Kaliyah Coa.
An “extensive search” has been carried out after the incident in east London at around 1.30pm on Monday.
Police said the child had been playing during a school inset day and entered the water near Barge House Causeway, North Woolwich.
A recovery mission is now said to be under way to find Kaliyah along the Thames, with the Metropolitan Police carrying out an extensive examination of the area.
Image: Barge House Causeway is a concrete slope in North Woolwich leading into the Thames
Chief Superintendent Dan Card thanked members of the public and emergency teams who responded to “carry out a large-scale search during a highly pressurised and distressing time”.
He also confirmed drone technology and boats were being used to “conduct a thorough search over a wide area”.
He added: “Our specialist officers are supporting Kaliyah’s family through this deeply upsetting time and our thoughts go out to all those impacted by what has happened.”
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“Equally we appreciate this has affected the wider community who have been extremely supportive. You will see extra officers in the area during the coming days.”
On Monday, Kerry Benadjaoud, a 62-year-old resident from the area, said she heard of the incident from her next-door neighbour, who “was outside doing her garden and there was two little kids running, and they said ‘my friend’s in the water'”.
When she arrived at the scene with a life ring, a man told her he had called the police, “but he said at the time he could see her hands going down”.
Barge House Causeway is a concrete slope that goes directly into the River Thames and is used to transport boats.
Residents pointed out that it appeared to be covered in moss and was slippery.