Children used as ‘objects for research’ while infection risks ignored, report saysChildren were used as “objects for research” while the risks of contracting hepatitis and HIV were ignored at a specialist school where boys were treated for haemophilia, the final report of the infected blood inquiry has found. PA Media says:
Of the pupils that attended the Lord Mayor Treloar College in the 1970s and 80s, “very few escaped being infected” and of the 122 pupils with haemophilia that attended the school between 1970 and 1987, only 30 are still alive.
Several pupils at the boarding school in Hampshire were given treatment for haemophilia at an on-site NHS centre while receiving their education.
But it was later found that many pupils with the condition had been treated with plasma blood products which were infected with hepatitis and HIV.
Haemophilia is an inherited disorder where the blood does not clot properly.
Most people with the condition have a shortage of the protein that enables human blood to clot, known as factor 8.
In the 1970s, a new treatment was developed – factor concentrate – to replace the missing clotting agent, which was made from donated human blood plasma.
The 2,527-page report, written by inquiry chair Sir Brian Langstaff, concluded that children at Treloar’s were treated with multiple commercial concentrates that were known to carry higher risks of infection and that staff favoured the “advancement of research” above the best interests of the children.
The report found that from 1977, medical research was carried out at Treloar’s “to an extent which appears unparalleled elsewhere” and that children were treated unnecessarily with concentrates, particularly commercial ones rather than alternative safer treatments.
Langstaff said: “The pupils were often regarded as objects for research, rather than first and foremost as children whose treatment should be firmly focused on their individual best interests alone. This was unethical and wrong.”
His report found there is “no doubt” that the healthcare professionals at Treloar’s were aware of the risks of virus transmission through blood and blood products.
He wrote: “Not only was it a pre-requisite for research, a fundamental aspect of Treloar’s, but knowledge of the risks is displayed in what the clinicians there wrote at the time. Practise at Treloar’s shows that the clinical staff were well aware that their heavy use of commercial concentrate risked causing Aids.”
Despite knowledge of the dangers, clinicians proceeded with higher-risk treatments in attempts to further their research, the report concluded.
Langstaff said: “It is difficult to avoid a conclusion that the advancement of research was favoured above the immediate best interest of the patient.”
The Lord Mayor Treloar College, which has since been rebranded as Treloar’s, was established in 1908 as a school which gave disabled children a better chance to receive an education alongside any medical treatment they might need.
It was originally a boys’ school but then merged with a girls’ school in 1978 to become co-educational.
From 1956, boys with haemophilia began attending the school. After it was discovered pupils had been given infected blood plasma, the NHS clinic at the school closed.
Key events
Langstaff says the use of surrogate testing could have reduced the risk. But he says there was a four-year delay in the UK before it was introduced.
He says a test for HIV was developed in August 1984. But it was not used to screen blood donations until October 1985, he says.
Langstaff said that the risk of infection from blood transfusions were known at least from the 1940s.
He quotes various pieces of evidence from health officials confirming this, including one person saying in 1946 that blood was a “potentially lethal fluid”.
And people knew that the risk was dependent on who the donors were, he says. The government knew there was a risk of collected blood from people in prison because of the increased danger from hepatitis. But that continued until 1984, he says.
He says in the UK people give blood voluntarily. But in the US people are paid to donate, and that is known to increase the risk of people with an infection donating, he says.
Despite this risk, in the 1970s the UK allowed the importation of blood products from America. That was wrong, he says.
Langstaff says ‘this disaster was not an accident’Langstaff says: “This disaster was not an accident.”
That generates a round of applause.
He says inquiries normally have a backward-looking aspect, into what happened, and a forward-looking one, into what should happen next.
But this one has had a third element: how did the government respond.
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.
He says that means it is important for the inquiry to ensure that in future people are not treated like this, and that the government responds “in a way which reflects the true facts”.
Langstaff says the report was handed to the Cabinet Office at 7am, and shown to campaigners, under embargo, from 8am.
He says there are seven volumes, with “quite a lot of detail”.
But he sums it up like this.
Families across the UK, people, adults and children, were treated in hospital and at home with blood and blood products and that NHS treatment resulted in over 30,000 people being infected with viruses, which were life shattering.
Over 3000 have already died. And that number is climbing week by week.
He says he could not adequately put into words what people suffered. Parents had to watch their children die, he says. And children watched their parents die.
He says the trauma continues to this day.
And he says in the past treatments for HIV and hepatitis C were often worse than the illness itself.
The side effects linger for a number of those infected with hepatitis C. The damage down over so many years to the liver has left them at risk of developing cancer, requiring liver transplants.
Every aspect of their lives have been defined by their infections – childhood education, career, leisure relationships marriages homeownership, travel, finances, dreams. Ambitions have been lost, relationships broken.
Brian Langstaff pays tribute to victims and campaigners as he makes statement about his reportSir Brian Langstaff is now speaking in Westminster Central Hall.
He receives a long round of applause from campaigners before he even starts.
He says that the applause is for the wrong person. He mentions his team. But he says the words in the report come from the campaigners and victims, the people in the room. He urges people to look around at each other. He goes on
Those are the people who have written this report, all from your very different perspectives.
The applause is loud, and sustained – and very moving.
Here is more from the Haemophilia Society on today’s report.
There’s so much to process and so much to say.
Here are some initial words from Kate, our Chief Executive, on a momentous day. pic.twitter.com/Ny39xiBlIx
— Haemophilia Society (@HaemoSocUK) May 20, 2024 Campaigners outside Central Hall in Westminster today, following the publication of the infected blood inquiry’s report. Photograph: Jeff Moore/PATheresa May ordered the infected blood inquiry when she was prime minister. She posted this reponse to the publication of its final report on X.
I hope that all those infected and affected by the contaminated blood scandal have got the answers they deserve today. Yet again, a community has had to fight for decades for the truth to come out. They shouldn’t have had to fight so hard or for so long for this day to come.
— Theresa May (@theresa_may) May 20, 2024 I hope that all those infected and affected by the contaminated blood scandal have got the answers they deserve today. Yet again, a community has had to fight for decades for the truth to come out. They shouldn’t have had to fight so hard or for so long for this day to come.
Sir Brian Langstaff is about to make a statement about his report. There will be a live feed here.
At 14.00, Inquiry Chair, Sir Brian Langstaff will give a statement setting out his findings and recommendations, followed by reflections from Inquiry participants. Watch it online here: t.co/e5uUZnzGeO
— Infected Blood Inquiry (@bloodinquiry) May 20, 2024 Jenni Minto, the Scottish government’s public health minister, has said the Scottish government will work with the UK government on compensation for victims of the infected blood scandal. In a statement she said:
On behalf of the Scottish government, I reiterate our sincere apology to those who have been infected or affected by NHS blood or blood products.
The Scottish government has already accepted the moral case for compensation for infected blood victims and is committed to working with the UK government to ensure any compensation scheme works as well as possible for victims.
The Scottish government has set up an oversight group to consider the inquiry’s recommendations for Scotland. That group will involve senior staff from NHS Boards and the Scottish government, along with charities representing the infected and affected.
We are determined to use the inquiry’s report to ensure lessons have been learned so a tragedy like this can never happen again.
At the press conference earlier Clive Smith, chair of the Haemophilia Society, said that many of those responsible for the infected blood inquiry would escape justice because it had taken so long to get to the truth of what happened. He said:
One of the aspects that sadly, the delay has caused, is the fact that there are doctors out there who should have been prosecuted for manslaughter, gross negligence manslaughter, doctors who were testing their patients for HIV without consent, not telling them about their infections.
Those people should have been in the dock for both gross negligence manslaughter. And sadly, because of the delay, that’s one of the consequences that so many people will not see justice as a result.
Clive Smith on Sky News Photograph: Sky NewsChildren used as ‘objects for research’ while infection risks ignored, report saysChildren were used as “objects for research” while the risks of contracting hepatitis and HIV were ignored at a specialist school where boys were treated for haemophilia, the final report of the infected blood inquiry has found. PA Media says:
Of the pupils that attended the Lord Mayor Treloar College in the 1970s and 80s, “very few escaped being infected” and of the 122 pupils with haemophilia that attended the school between 1970 and 1987, only 30 are still alive.
Several pupils at the boarding school in Hampshire were given treatment for haemophilia at an on-site NHS centre while receiving their education.
But it was later found that many pupils with the condition had been treated with plasma blood products which were infected with hepatitis and HIV.
Haemophilia is an inherited disorder where the blood does not clot properly.
Most people with the condition have a shortage of the protein that enables human blood to clot, known as factor 8.
In the 1970s, a new treatment was developed – factor concentrate – to replace the missing clotting agent, which was made from donated human blood plasma.
The 2,527-page report, written by inquiry chair Sir Brian Langstaff, concluded that children at Treloar’s were treated with multiple commercial concentrates that were known to carry higher risks of infection and that staff favoured the “advancement of research” above the best interests of the children.
The report found that from 1977, medical research was carried out at Treloar’s “to an extent which appears unparalleled elsewhere” and that children were treated unnecessarily with concentrates, particularly commercial ones rather than alternative safer treatments.
Langstaff said: “The pupils were often regarded as objects for research, rather than first and foremost as children whose treatment should be firmly focused on their individual best interests alone. This was unethical and wrong.”
His report found there is “no doubt” that the healthcare professionals at Treloar’s were aware of the risks of virus transmission through blood and blood products.
He wrote: “Not only was it a pre-requisite for research, a fundamental aspect of Treloar’s, but knowledge of the risks is displayed in what the clinicians there wrote at the time. Practise at Treloar’s shows that the clinical staff were well aware that their heavy use of commercial concentrate risked causing Aids.”
Despite knowledge of the dangers, clinicians proceeded with higher-risk treatments in attempts to further their research, the report concluded.
Langstaff said: “It is difficult to avoid a conclusion that the advancement of research was favoured above the immediate best interest of the patient.”
The Lord Mayor Treloar College, which has since been rebranded as Treloar’s, was established in 1908 as a school which gave disabled children a better chance to receive an education alongside any medical treatment they might need.
It was originally a boys’ school but then merged with a girls’ school in 1978 to become co-educational.
From 1956, boys with haemophilia began attending the school. After it was discovered pupils had been given infected blood plasma, the NHS clinic at the school closed.
Inquiry chair Brian Langstaff says infected blood scandal suffering ‘very difficult to put into words’Sir Brian Langstaff, the chair of the infected blood inquiry, told broadcasters after his report was published that it was hard to explain the scale of the suffering involved. He said:
The scale speaks for itself, if you have over 30,000 people who go into hospital and come out with infections which were life-shattering that in itself is huge and the suffering for them and others is huge.
When you add that the fact that over 3,000 have died and deaths keep on happening week after week, you not only have a disaster that has happened over years but is still happening.
What that brings with it is suffering which is very difficult to put into words, you really have to listen to people who have lived with it to hear and understand.
He also said that the government made things worse.
What I have been looking at are people from families across the UK who have gone into hospital for treatment and over 30,000 have come out with infections which were life-shattering.
And 3,000 of those have died and deaths keep on happening week-by-week. What I have found is that disaster was no accident. People put their trust in doctors and the government to keep them safe and that trust was betrayed.
Then the government compounded that agony by telling them that nothing wrong had been done, that they’d had the best available treatment and that as soon as tests were available they were introduced and both of those statements were untrue.
That’s why what I’m recommending is that compensation must be paid now and I have made various other recommendations to help make the future of the NHS better and treatment safer.
Sir Brian Langstaff, chair of the infected blood inquiry, speaking to campaigners in Westminster today. Photograph: Jeff Moore/PA‘Suffering that is hard to comprehend’: key takeaways from UK infected blood reportHere is Rachel Hall’s summary of the key takeaways from the report.