Authorities covered up the infected blood scandal after knowingly exposing victims to unacceptable risks, a long-awaited report, external says.
The five-year investigation accused doctors, government and the NHS of letting patients catch HIV and hepatitis.
More than 30,000 people were infected from 1970 to 1991 by contaminated blood products and transfusions.
About 3,000 have since died and more deaths will follow.
The Infected Blood Inquiry said victims had been failed “not once but repeatedly” by doctors, the NHS, government and others responsible for their safety.
Patient safety was not paramount in decision-making, it said, 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.
Despite this, people were exposed to “unacceptable risks”, including:
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the continued importation of blood products from abroad – which included blood from high-risk donors in the US where prisoners and drug addicts were paid to give blood – despite a pledge to become self-sufficient
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the failure of the licensing regime to recognise such products were unsafe and should not have been licensed for use
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the continued sourcing of blood donations from high-risk populations in the UK too, such as prisoners, until 1986
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taking until the end of 1985 to heat-treat blood products to eliminate HIV, despite the risks being known since 1982
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the government ignoring warnings in 1983 from one of the UK’s top infectious disease experts Dr Spence Galbraith that all imported US blood products should be withdrawn from NHS use until the HIV risk was “clarified”
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a lack of testing from the 1970s onwards to reduce the risk of hepatitis
Inquiry chairman Sir Brian Langstaff described the scale of what happened as “horrifying” and said the authorities had been too slow to respond to the risks.
Addressing the issue of a cover-up, he said that better wording to describe it was “hiding the truth”.
He said there has been 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 telling half-truths or not telling people what they had a right to know – including the risks of treatment they received, what alternatives were available and, at times, even the fact that they were infected.
Sir Brian said the scandal had destroyed “lives, dreams, friendships, families and finances”, adding the numbers dying were still climbing week by week.
“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,” he said.
He was also critical of the delays to calling a public inquiry – the then-Prime Minister Theresa May only announced it in 2017 when under political pressure.
Sir Brian said the fact it took so long has hampered his investigation as key people have since died or have been too frail to give evidence.
He said he had looked at over 50 years of decision-making and said there had been an “institutional defensiveness” by the NHS and government that had compounded the harms that had been done.
Two main groups of people were caught up in the scandal.
One was people with haemophilia, and those with similar disorders, who have a rare genetic condition which means their blood does not clot properly.
In the 1970s, a new treatment was developed to replace the missing clotting agents, made from donated human blood plasma.
The second group affected include people who had a blood transfusion after childbirth, accidents and during medical treatment.
Blood used for these patients was not imported, but some of it was also contaminated, mainly with hepatitis C.
Sir Brian’s two interim reports, published in July 2022 and April 2023, made recommendations about compensation for victims and their families.
The government has said it accepts the “moral case” for compensation, and interim payouts of £100,000 each have already been made to about 4,000 survivors and bereaved partners.
Ministers have promised to address the issue of final compensation once the inquiry’s report is published. The total cost is likely to run into billions.
Clive Smith, of the Haemophilia Society, said the findings of the report 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.”
And he said it was vital the government now acted. “Why is it in the UK we continue to have these scandals?,” he added.
“We don’t listen to the recommendations of public inquiries, and that has got to stop today”.
Prime Minister Rishi Sunak is expected to issue an apology later on Monday.
Behind the Story: The infected blood scandal
Health Editor Hugh Pym and Senior Producer Chloe Hayward go behind the story of the infected blood inquiry.
