The final report of the Infected Blood Inquiry has been handed down today, 20 May 2024. The Infected Blood Inquiry investigated “the worst treatment disaster in the history of the NHS”, as Lord Robert Winston called it, and the Inquiry’s report echoed.

Steven Snowden KC of 12KW (instructed by Collins Solicitors) led Dr Achas Burin of 12KBW and Brian Cummins of Old Square Chambers, representing the largest group of infected and affected individuals at the Inquiry (1,500+ core and non-core participants).

1,250 people with bleeding disorders died of AIDS, of whom 380 were children. Infections were “caused needlessly”, the report states.

The report vindicates what infected patients and their families had been trying to draw to public attention since the 1970s and 1980s. The infections were transmitted by medical treatment involving blood (e.g. transfusion) or clinical products derived from human blood (such as those used to treat clotting diseases). The blood and blood products were contaminated by HIV, hepatitis, or both.

As a result, more than 3,000 people died as a result of infection without seeing this report published and their experiences committed to public record. Their experiences, as well as successive governments’ responses to them, is roundly condemned by Sir Brian Langstaff, the Inquiry’s Chair. In his final report, he stated plainly: “The scale of what has happened is horrifying.”

There were “systemic, collective and individual failures to deal ethically, appropriately and quickly with the risk of infections” as well as the infections themselves. This “calamity” could have been “largely, but not entirely, avoided” and – what is more – “it should have been.” Instead, infected patients as well as their “partners, family, children, friends” have “suffer[ed] in almost every aspect of their lives.”

Approximately 26,800 people were infected with Hepatitis C following blood transfusions. The value of the Inquiry was felt even before its report was published, with over 12,000 people applying for home-testing kits for Hepatitis C (‘the silent killer’) in the week before the publication of the final report. This number is five to six times greater than the entire previous month, the BBC reported.

The Sunday Times reported that the Prime Minister is expected to make an apology today, and announce a compensation scheme totalling around £10bn. This was also supported by Sir Keir Starmer, leader of the Labour Party, who would uphold the commitment in the event of a change of government following any General Election.

As can be seen, the course of the Infected Blood Inquiry and, indeed, its final report rewards close study. Sir Brian Langstaff said: “The way in which institutions, and in particular the government, responded to what had happened after 1985 was in many respects shameful. This should never happen again.”

Our Inquests & Inquiries blog hosts a more detailed precis of the Inquiry’s final report, together with an analysis of its wider lessons for practitioners.