Infected blood scandal: “Chilling” cover up hid truth for decades, public inquiry finds

A cover up by the NHS and the UK government hid the truth for decades from tens of thousands of people infected by blood products or blood transfusions, the judge chairing the public inquiry into the worst treatment disaster in NHS history has concluded.1

“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,” said the report by the retired High Court judge Brian Langstaff. “To save face and to save expense, there has been a hiding of much of the truth.”

The six year public inquiry into how 30 000 people—those with haemophilia who were treated with blood products and patients who received blood transfusions—came to be infected with HIV and hepatitis C found that documents were deliberately destroyed. A government report on why the UK had not become self-sufficient in blood products earlier than it did was “redrafted to hide significant information.”

Over the years government ministers parroted “lines to take” devised by civil servants that were “inaccurate, defensive, and misleading.” Ministers made untrue statements that patients had received the best possible treatment and that infections were “inadvertent.”

“This disaster was not an accident,” said Langstaff at the report’s launch. “The NHS and successive governments compounded the agony by refusing to accept that wrong had been done. The government repeatedly maintained that people received the best available treatment and that testing of blood donations began as soon as technology was available, and both claims were untrue.” He added that NHS treatment with blood and blood products had resulted in 30 000 people being infected with viruses and that more than 3000 had died. Deaths were continuing every week.

For decades the government refused to hold a public inquiry. “Its persistent refusal to hold a public inquiry, coupled with a defensive mindset that refused to countenance that wrong had been done, left people without answers, and without justice,” said the report.

It was long known in medical and government circles that blood products carried the danger of infection with hepatitis. In 1975 David Owen, then health secretary, announced in parliament that he expected national self-sufficiency in blood products to be achieved within two or three years. In 1987 he discovered that it had still not been achieved, and when he asked to see the papers covering his term in office he was told that they had been destroyed under the “10 year rule.”2

Patients with haemophilia had been treated with cryoprecipitate, but clinics started treating them with factor VIII made by US drug companies using blood from multiple paid donors recruited from risky populations such as prisoners and people in poverty. “Clinicians decided to give their patients (a variety of) factor concentrates as a matter of convenience,” said the report, which concluded that most infections could and should have been avoided.

The then Department of Health and Social Security and doctors treating haemophilia were alerted to the possibility of HIV being transmitted through blood in 1982, and the death of the first UK haemophilia patient from AIDS was confirmed in August 1983. But two months later Arthur Bloom, chairman of the UK Haemophilia Centre Directors Organisation, who died in 1992, told the organisation’s annual meeting that “he felt that there was no need for patients to stop using the commercial concentrates because at present there was no proof that the commercial concentrates were the cause of AIDS.”

Around 1250 people with bleeding disorders were infected with HIV, three quarters of whom have died.

Patients and the parents of those who were children were not told of the risks of the treatment and given the alternative of safer treatment, such as cryoprecipitate. Pupils at Treloar’s School in Hampshire, which had an NHS haemophilia centre on site, were treated as “objects for research,” with clotting factor concentrates used “indiscriminately.” Risks were not properly explained to their parents. Of the 122 pupils with haemophilia who attended the school between 1970 and 1987 only 30 survive.