Jim Reed
Reporting from the inquiry

This inquiry has also been asked to investigate how victims of this scandal and their families were treated in the decades after they were infected.

Again it highlights a series of failures by government and the health authorities including:

• The absence of any meaningful apology and redress
• The “repeated use” of inaccurate, misleading and defensive lines which “cruelly told people that they had received the best treatment available”
• A “lack of openness, transparency and candour” from the NHS and government
• Long delays in providing support payments and a refusal to provide compensation

It also criticises the decision by successive governments to reject calls for a public inquiry by producing “flawed, incomplete and unfair” internal reports.

Sir Brian Langstaff, the chair of the inquiry, said it will be “astonishing to anyone who reads this report that these events could have happened in the UK”.

The families affected had been subjected to “a level of suffering which is difficult to comprehend, still less understand,” he adds, which was “compounded by the reaction of the government, NHS and other public bodies”.

As we've been reporting, one of the campaigners has said that the finding in the report that there is evidence of a cover-up is "no surprise".

Clive Smith, chairman of the Haemophilia Society, added that "we have known that for decades and now the country knows and now the world knows as well."

He was speaking alongside other campaigners at a press conference a little earlier. You can watch his reaction to the report in the clip below.

Jim Reed
Reporting from the inquiry

In 1981, the first reports started to emerge about a new disease which would later become known as Aids.

By the end of 1982, the inquiry says, ”all those involved in treating patients with blood or blood products either knew, or should have known, of the risks.”

Throughout 1983, the warnings signs were growing louder.

In May 1983, one of the UK’s top infectious disease experts Dr Spence Galbraith, wrote to the Department of Health saying that all imported American blood products should be withdrawn from NHS use until the aids risk was “clarified”.

Yet that didn’t happen and the contaminated American products continued to be used.

The inquiry heavily criticises the decision not to suspend the importation of those products at the time and also for failing to keep the situation under review.

At the time government ministers were saying in parliament that there was still “no conclusive proof” that HIV could be transmitted in blood.

The inquiry says that was the “wrong approach” which was “falsely reassuring the public and patients”.

Instead politicians and officials should have been asking if “there was a real risk blood might transmit [HIV],” it says.

Nick Triggle
Health Correspondent

The public inquiry makes it clear we should not have waited so long to get this point. It has looked over more than 50 years of government decision-making, saying there has been an "institutional defensiveness" by the NHS and government which has compounded the harms that have been done.

Campaigners have always been critical of how long it has taken to get a public inquiry.

In other countries that faced contaminated blood scandals, including France and Japan, investigations into the medical disasters were completed many years ago.

In some cases, criminal charges were brought against doctors, politicians and other officials.

In the UK, a private inquiry in 2009 - funded entirely by donations - lacked any real powers, while a separate Scottish investigation in 2015 was branded a "whitewash" by victims and their families.

This public inquiry was only agreed to in 2017 by the then-Prime Minister Theresa May under political pressure.

Inquiry chair Sir Brian Langstaff said the delays getting to this point had meant it had been more difficult to get at the truth with key people involved having died or being too frail to give evidence. It also meant it was harder to get access to information and documents than it would have been in earlier years.

A reporter asked about the words used in the report to describe former health secretary Lord Clarke, among which was combative.

Clive Smith says he spent three days watching him give evidence and that he was "patronising in the extreme".

He adds that Lord Clarke had clearly never met anyone with Haemophilia. For the Health Secretary not to sit down with that community is "appalling", he says.

Jason Evans adds that Clarke asked whether Factor VIII was a pill. Jason says he used that to ask the media to assist with public understanding about the product.

Image source, Pool

Sue Wathen says cost is a huge factor in this, and "it's going to cost much much more".

"That's just in monetary terms, I'm not thinking about the loss of life, which is the most unbearable cost," she added.

Clive Smith adds that we "continue not to learn from failures", drawing similarities to the post office scandal.

"Had this inquiry happened decades ago when it should have, might the post office scandal have been avoided? Possibly."

Andy Evans says "the ball is in the government's court" as he praises the chair for his "excellent" public inquiry.

"Only when we have their response on compensation we can judge whether it has been successful," Clive Smith adds.

Some court cases have been paused while the inquiry makes its final report.

Jason Evans says that regarding the group litigation in his name against the Department of Health - it will depend on what the government does now and how they come forward tomorrow with compensation proposals.

That will help decide what to do with the case next.

Other litigations are also ongoing.

Image source, Pool

Clive Smith is speaking again now

"There is an unprecedented aspect to his inquiry," he says.

"Sir Brian [the inquiry chairman] is not sending his final report today, the government will have to provide a report to the government within 12 months - what the chair is saying to government is 'I don't trust you', and that is what the community has been saying for years".

"Why is it in the UK we continue to have these scandals?," he says.

"We don't listen to the recommendations of public inquiries, and that has got to stop today".

The victims have been asked if any complaints have been made to the police - although the inquiry did not have a remit to recommend prosecutions.

Clive Smith says he is not aware of any calls to police at this stage, but he says the delays have lead to "doctors out there who should have been in the dock for gross negligence manslaughter".

The campaigners are asked what they would say to politicians both in charge now and throughout the time of the scandal.

Clive Smith says that many politicians should "hang their heads in shame". He wants them to start to acknowledge their part, underlining that no single person is responsible.

He says that although there may be an apology from the Prime Minister later, it's not just him who holds responsibility and accountability - he wants many more people to come forward and say sorry.

Another calls for a proper apology from pharmaceutical companies.

Clive Smith, another victim of the scandal, says it was "no surprise to our community" that there was a cover up.

"Now the country knows and the world knows, there was a deliberate attempt to lie and conceal, this was systemic, by government, civil servants and healthcare professionals".

"It was an abuse by people who were supposedly there to care for us," added Sue Wathen.

Image source, Pool

We are now hearing from some of the victims who say today is a momentous day for all of us.

"Sometimes we felt we were shouting into the wind for 40 years," says Andy Evans

Evans says he feels "validated and vindicated" by Sir Brian Langstaff's report.

We'll continue to bring you what is said by the victims, or you can watch it live by pressing Play at the top of this page.

What could the inquiry’s findings mean for victims?published at 12:44 British Summer Time 20 May

12:44 BST 20 May

Jim Reed
Health reporter

This inquiry is what campaigners have called the “defining moment” in their decades-long “fight for answers”.

But it might not draw a line under the scandal.

In 2017 a group of more than 500 victims were given permission to sue the Department of Health for damages.

That legal action was suspended in late 2018 because of the inquiry, but could start back up again depending on the strength of the findings and the government’s response.

Other civil cases are also on hold, including one against Treloar’s College in Hampshire, where more than 120 young haemophiliacs are thought to have been infected at the NHS-run centre on site.

A former health secretary, Andy Burnham, has called the scandal “one of the greatest injustices this country has ever seen.”

Last week, he told BBC Breakfast that he was “not told the truth” by officials, and has suggested that charges of corporate manslaughter could be considered in the future.

Jim Reed
Reporting from the inquiry

Around 1,250 haemophiliacs and those with similar bleeding disorders were infected with HIV in this scandal, including 380 children. Around three quarters of those died of aids before modern antiretroviral drugs became available.

Many were infected after being given a contaminated form of a new treatment for the condition, called Factor VIII, which was imported from the United States.

The report says there was an “attitude of denial” about the risks at the time. Instead haemophiliacs were treated with “increasing volumes” of Factor VIII.

The report highlights a number of failings including:

• The health authorities were “too slow” to respond to the risks
• Patients could have been switched back to older treatments, and the amount of riskier Factor VIII could have been restricted
• There was a “failure in the licensing regime” for imports which were “understood to be less safe than domestic treatments”.
• The “inept, fragmented system” of blood donation across the UK at the time meant there was a failure to ensure a sufficient supply of Factor VIII from UK donors.
• There was also a failure to finance research into ways of heating the treatment to kill HIV and viruses.
• There is evidence children were treated unnecessarily with unsafe treatments and some were used as “objects of research”

Jim Reed
Reporting from the inquiry

Sir Brian Langstaff’s report tackles one of the enduring myths of this scandal head on.

He is clear that the infections and deaths of patients were in no way a terrible historical accident.

“I have to report that [the disaster] could largely, though not entirely, have been avoided. And I have to report that it should have been,” he writes. He describes the scale of what happened as “horrifying”.

He says it was “well known” from at least the early 1940s that the hepatitis virus could be transmitted in blood. And - crucially - says that it was “apparent” by mid 1982 that whatever was causing Aids might be also be in spread in this way.

Yet the NHS continued to import contaminated treatments from the US.

Infections, leading to deaths, illnesses and suffering were “caused needlessly” to people with haemophilia and other bleeding disorders, added Sir Brian.

He said thousands of NHS patients who needed a blood transfusion were also exposed to hepatitis C partly because there was a sense of “complacency” over the dangers of the virus.

Nick Triggle
Health Correspondent

The inquiry was specifically asked to explore whether there was any evidence of a cover-up.

Inquiry chair Sir Brian Langstaff is clear – there is, although he prefers the term “hiding the truth”.

He says there was a lack of openness, inquiry, accountability and elements of “downright deception”, including destroying documents.

But he said hiding the truth included not only deliberate concealment, but also telling half-truths or not telling people what they had a right to know.

He said this included the risks of treatment they received, what alternatives were available and, at times, even the fact that they were infected.

Nick Triggle
Health Correspondent

The Infected Blood Inquiry said its victims had been failed "not once but repeatedly" by their doctors, by bodies including the NHS and others responsible for their safety, and the government.

It criticised the failure to make patient safety paramount in decision-making, pointing out the risk of viral infections being transmitted in blood and blood products had been known about since the start of the NHS in 1948.

But it said despite this people were exposed to "unacceptable risks".

This included:

• Not doing enough to stop importing blood products from abroad – which included blood from high-risk donors in the US where prisoners and drug addicts were paid to give blood
• Continuing to source blood donations from high-risk populations in the UK too such as prisoners until 1986
• Taking until the end of 1985 to heat-treat blood products to eliminate HIV despite the risks being known since 1982
• Not introducing as much testing as could have been done to reduce the risk of hepatitis from the 1970s onwards

Nick Triggle
Health Correspondent

We're just now able to bring you the key lines from the infected blood inquiry's final report.

The scandal could and should have been largely avoided, it concludes.

The five-year investigation also accuses doctors, the government and NHS of trying to cover-up what happened.

The report says patients were exposed to "unacceptable risks", including not doing enough to stop importing blood products from abroad, which included blood from high-risk donors in the US.

Rajini Vaidynathan
Reporting from Methodist Central Hall in Westminster

In an inquiry which has impacted thousands of lives, every story paints a picture of the scale and intensity of what happened. It’s a day of high emotion.

“I feel angry,” Theresa told me as she arrived at the Methodist Central Hall. As she held back tears, she told me about her mother Carine, who died in 1995.

Carine had a transfusion in 1982 and was infected back then. A few years later she was told she had HIV, and then years after also learnt she had hepatitis C.

Theresa wants her mum’s story to be remembered.

The report will be publicly released from 12:30 BST