Infected Blood Scandal: Thoughts from our Expert

Our medical negligence specialist Viral Dagly shares with us his thoughts on the infected blood scandal, a topic of high prominence in the media this week. The inquiry has published its final report which largely concludes that the scandal could have, and should have been avoided.

The scandal

According to the BBC sources, more than 30,000 people were infected with HIV and hepatitis C between 1970 and 1991 by “contaminated blood products and transfusions”. But it’s not just the contaminated treatment that thousands of individuals are calling out – it’s also the fact that the victims were seemingly betrayed by the NHS and government’s attempts to cover it up.

There has been a five-year investigation into the scandal. Inquiry chairman Sir Brian Langstaff says: “This disaster was not an accident. The infections happened because those in authority – doctors, the blood services and successive governments – did not put patient safety first… There has been a lack of openness, inquiry, accountability and elements of downright deception, including destroying documents.” (BBC).

Who was given infected blood?

Two main groups of patients were affected by the contaminated blood; those receiving treatment for haemophilia, and anyone who was undergoing a transfusion during surgery or other medical treatment, or following childbirth.

It is said that approximately 1,250 people with haemophilia were given infected blood as part of a new treatment in 1970, which used donated blood plasma to replace missing clotting agents. This caused the development of HIV and hepatitis C, which can both cause fatal illnesses and long-term health conditions. Many patients gave HIV to their partners unknowingly and approximately two-thirds of the 1,250 later died of illnesses relating to HIV.

According to the BBC, around 2,900 people have died as a result of this scandal.

Key points from the report

During that time period the UK was severely lacking in blood products to treat haemophilia, so these (specifically Factor VIII) were imported from the US. The batches were each made of pooled or mixed blood plasma from thousands of donors – but, if just one donor was HIV-positive, it could mean an entire batch was infected. The donors were also part of high-risk groups such as prisoners and drug users.

The report says: “Too little was done to stop importing blood products from abroad, which used blood from high-risk donors such as prisoners and drug addicts… It took until the end of 1985 to heat-treat blood products to eliminate HIV, although the risks were known in 1982.” It also took 18 months after hepatitis C was first discovered for blood donations to start being routinely screened for it.

The report also mentions an “attitude of denial” regarding the risks of using imported blood products, and an increase in treatment volumes despite the risks of viral transmission being known. There is also the point relating to patients with haemophilia being offered an alternative treatment – cryoprecipitate, which would have been safer.

“Adopting the wrong approach by looking for conclusive proof of what was the cause of AIDS rather than asking if there was a real risk that blood might transmit it” is another point published in the report. Generally, it seems there was a complete lack of accountability and a huge failure to take such high risks seriously in any capacity.

Thoughts from Viral Dagly

“This was one of the NHS’ biggest treatment disasters and in turn, there are thousands of patients, together with their loved ones, who will have been adversely affected. Until more recently, victims have been denied access to justice, victims have been denied access to financial redress and importantly and victims were denied a comprehensive and fair investigation.

It is a difficult pill to swallow when we comment on another national scandal that has adversely impacted patient safety, especially when we see the same themes repeated over and over.

Arguably, our society, attitudes to the NHS and attitudes to paternalistic medicine have changed since the events that led to these significant failings took place.

We know that there still needs to be a significant change in culture within the NHS, a focus on shared learning from mistakes, better funding of services and improved levels of staffing. All of these should lead to an improvement in patient safety issues. Whilst these issues are frequently cited as causes, there is little evidence that the appropriate action is being taken and it is difficult to know whether there is improvement.

One such factor that has stuck out for me from the report is ‘delay’. When a patient is harmed, there is often a significant period of delay (months/years) before it is acknowledged that the patient may have been harmed. By this point, it can be too late to commence any effective treatment and the damage has been done to the patient’s work and family life. The Inquiry report notes that there were a number of systemic delays, which have prevented access to redress from these victims.

The Prime Minister has announced that comprehensive compensation will be paid to those affected and infected after receiving infected blood. We have heard this before, whether that be to compensate those impacted by Windrush or the Post Office/Horizon scandal. Both compensation schemes have widely reported to have significant hurdles and issues.

The easy approach will be to offer ballpark or standardised figures of compensation, to expedite the process. However, arguably, this will not correctly take into account the impact on individual families; the impact on the livelihoods of those who were harmed or the care their families will have provided. An effective ‘claims protocol’ needs to be agreed, to allow for claims to be processed and progressed.”