Infected Blood Inquiry: key findings

Readers cannot have failed to miss the publication of the Infected Blood Inquiry report last month.

As the report runs to seven volumes, we thought it might be helpful to draw out of it points which we think will be of interest to a wider audience - not just those who may have been involved to some greater or lesser extent in the treatment of patients who require blood products but those involved in risk management and governance in the health and care sector. There is something in here for everyone.

Sir Brian Langstaff was appointed chair back in February 2018.

Over six years later he states:

“Lord Winston famously called these events the worst treatment disaster in the history of the NHS. I have to report that it could largely, though not entirely, have been avoided.  And I have to report that it should have been. I have also to report systemic, collective and individual failures.”

The summary of his report is set out at pages 2-7 of volume one.

Six themes were prominent

1. Patient safety: A failure to make patient safety the paramount focus of decision-making and of action.
2. Decision making: The slow and protracted nature of much of the decision-making examined.
3. Patient autonomy: The profoundly unethical lack of respect for individual patient autonomy.
4. Clinical freedom: Clinical freedom is the idea that doctors should be free to do what they believe to be right for an individual patient. But the danger of clinical freedom in the context of infected blood and blood products is that it allowed doctors to follow unsafe treatment policies and practices and it meant that others (in particular the health departments and chief medical officers) held back from providing advice, guidance or information in the misguided belief that this would interfere with clinical freedom.
5. Institutional defensiveness: From the NHS and in particular from government, compounded by group think among civil servants and ministers, and a lack of transparency and candour. These factors drove the response of government over the decades. Institutional defensiveness identified is damaging to the public interest.
6. Damage: The damage that was done by that defensiveness and the accompanying lack of transparency and candour to the very people whose lives had been destroyed by infection. The harms already done to them were compounded by the refusal to accept responsibility and offer accountability, the refusal to give the answers that people fervently sought, the refusal to provide compensation, leaving people struggling and in desperate circumstances, the thoughtless repetition of unjustified and misleading lines to take, and the lack of any real recognition and of any meaningful apology.

Sir Brian Langstaff notes that officials were seeking legal advice on the effect on the Department of Health (DH) of apologising and using the term “health disaster” at one point. To him this suggested that the primary focus may have been reputational or litigious consequences for the DH rather than the position of those whose lives, and the lives of those close to them had been devastated.

Sir Brian observes that successive governments were more concerned about reputational damage than openness and honesty, more defensive than candid, more interested in avoiding financial exposure than in admitting shortcomings.

He notes how Jeremy Hunt described as the “massive institutional reluctance in the NHS to listen to the stories of ordinary people when things have gone wrong … there was certainly a very strong view that harm to patients is part of the cost of doing business. It’s part of what happens.” Sir Brian states that description is as equally applicable to government as to the NHS.

The evidence before the Inquiry that the truth was concealed or suppressed is overwhelming.

Just as the NHS responded defensively, so too did successive governments. It assumed, without listening to the patients themselves, that doctors and the NHS had done nothing wrong and that the risks had been explained. Financial and reputational considerations predominated.

Standing back and viewing the response of the NHS and of government, the answer to the question “was there a cover up?” is that there has been. Not in the sense of a handful of people plotting in an orchestrated conspiracy to mislead, but in a way that was more subtle, more pervasive and more chilling in its implications. To save face and to save expense, there has been a hiding of much of the truth.

Final words

Sir Brian states that where things appear to have gone wrong and safety has been compromised, an attempt should be made to learn the lessons as quickly as possible.

Central themes running through most aspects of the Inquiry were as follows:

1. First and foremost, patient safety should have been the paramount, guiding principle.
2. Second, a search for certainty can be, and in this case was, an enemy of achieving progress.
3. Third, risks to public health need to be addressed with speed, consistency, and an objective look at such evidence as there is without making unjustified assumptions.
4. Fourth, what aids the process is a clear structure for decision-making. Instead of effective decision-making here, there was “decision paralysis”.
5. Finally, cost, though a relevant factor, should not be the starting point. Patient safety should be.