The chair of a public inquiry into the infected blood scandal, that has led to 30,000 people being infected with ‘life shattering’ viruses and over 3,000 deaths so far, has said the scandal was not an accident and he expects the government to apologise. Sir Brian Langstaff (pictured above, left) also called for a statutory duty of candour to be imposed on civil servants as well as healthcare leaders in the wake of his findings.
Shortly after the Infected Blood Inquiry published its final report, which is divided into seven volumes, Langstaff took to the stage at Central Hall in Westminster.
Langstaff said adults and children were treated in hospital and at home with blood and blood products. ‘That NHS treatment resulted in over 30,000 people being infected with viruses which were life-shattering. Over 3,000 have already died and that number is climbing week by week… Parents watched their children suffer and, in many cases, die. Children witnessed the decline and death of one, sometimes both parents, their lives irrevocably altered as a result. People had to care for their grievously ill partners or family members often at the expense of their own health and careers. Early on in particular, they had to do so whilst being shunned or worse abused, by neighbours, workmates, by people they once thought of their friends, sometimes even by health professionals.’
Langstaff declared: ‘This disaster was not an accident. People put their faith in doctors and the government to keep them safe – and their trust was betrayed.’
Langstaff said there were generally two elements to any major public inquiry – one was backward-looking (what happened and why) and one was forward-looking (what next). The Infected Blood Inquiry had a third element: what was the response of government and others in authority to what had happened. ‘Here, the NHS and successive governments compounded the agony by refusing to accept that wrong had been done. More than that, the government repeatedly maintained that people received the best available treatment and that testing of blood donations began as soon as the technology was available. And both claims were untrue.’
On lessons to be learned, he said patient safety must be the ‘guiding principle’, risks should be properly understood and communicated, and the public should be ‘trusted with the truth with all its uncertainties’.
‘I fully expect the government to make an apology,’ Langstaff added. ‘To be meaningful, that apology must explain what the apology is for. It should recognise and acknowledge not just the suffering but the fact the suffering was a result of errors, wrongs done and delays incurred. It should provide vindication to those who have waited for that for so long.’
Actions to accompany that apology should include a proper compensation scheme, Langstaff said to huge applause.
Ensuring a ‘patient safety culture’ was not an easy task. Langstaff recommended that individuals should be obliged to report ‘near misses’ as well as actual wrongs. Healthcare leaders should be made subject to a statutory duty of candour where they are not already. The regulatory landscape for patient safety should be ‘decluttered’.
To end a ‘defensive culture’ in the civil service and government, Langstaff encouraged the government to reconsider whether, in light of the facts revealed in the inquiry, ‘it is sufficient to continue to rely on current non-statutory duties in the civil service code and ministerial codes’.
He recommended a statutory duty of accountability on senior civil servants for the candour and completeness of advice given to permanent secretaries and ministers, and of their responses to concerns raised by the public and their own staff.
The power to call an inquiry remains for the minister under the Inquiries Act. But Langstaff believed there is a role for the House of Commons public administration and constitutional affairs select committee to consider whether to recommend to a minister to exercise their power. If a minister disagrees, they must set out in detail and publish reasons for the disagreement ‘sufficient to satisfy the committee that the matter has been carefully and properly considered’.
