Infected blood inquiry report published

The infected blood inquiry, chaired by Sir Brian Langstaff, has now concluded.1 It is the largest public inquiry ever carried out in the UK, investigating what has been described as the ‘worst treatment disaster in the history of the NHS’.1 2 It was established to examine the circumstances in which more than 30 000 people in the UK were infected with HIV and hepatitis C after being given contaminated blood and blood products during the 1970s and 1980s, which had been imported to meet the demand for a new blood-clotting treatment known as ‘factor VIII’. This treatment was created by pooling the plasma from thousands of donors, increasing the risk of infection. The risk was further heightened by the inclusion of donor plasma from the USA, where people with a high risk of infection, including prisoners, were paid to provide blood, whereas the UK system has always relied on altruistic donation.3

The inquiry gathered extensive evidence and was informed by the involvement of over 2000 infected individuals. It considered questions of informed consent, openness and transparency, including disclosure of risks. In his report, Sir Langstaff concluded that the scandal "could largely, though not entirely, have been avoided" and resulted from "systemic, collective and individual failures to deal ethically, appropriately and quickly, with the risk of infections being transmitted in blood, with the infections when the risk materialised and with the consequences for thousands of families". He highlighted six themes arising from the inquiry:

• A failure to make patient safety the paramount focus of decision-making and action.

• The protracted nature of much of the decision-making.

• A profoundly …