Infected Blood Inquiry

Baroness Twycross Excerpts

Tuesday 15th October 2024 Lords Chamber

Moved by

[Baroness Twycross]

That this House takes note of the response to the Infected Blood Inquiry.

[The Parliamentary Under-Secretary of State, Department for Culture, Media and Sport (Baroness Twycross) (Lab)]

My Lords, almost five months have now passed since Sir Brian Langstaff published the final report of the infected blood inquiry on 20 May. I am grateful for this opportunity to debate the contents of that report, having now had the time to digest the contents of the very comprehensive report in full. I begin by paying tribute to Sir Brian and his team for the dedication and time that went into delivering this crucial report. The inquiry has handled an immensely challenging and sensitive issue with extreme care, and it is as a result of its commitment that the truth has finally been uncovered.

I also offer my gratitude to those in the infected blood community who came forward to participate in the inquiry. Their courage in doing so was immense; the Government and the nation owe them our utmost thanks.

I thank noble Lords who have played a prominent role in bringing the work to this point for the important contributions they have made in this House. In particular, I thank the noble Earl, Lord Howe, who, through the Victims and Prisoners Act, put in place the legislation that provides the necessary legal framework to establish the Infected Blood Compensation Authority and enables the set-up of the infected blood compensation scheme through regulations.

Sir Brian’s report laid bare the unforgivable failures of the state, and the deep-rooted and long-lasting trauma that has been inflicted on the victims of this scandal. I reiterate the unequivocal apology on behalf of this Government and Governments past. The infected blood scandal is a subject of national shame and nothing can ever fully right the wrongs done to those impacted.

Particularly distressing is the treatment of children who were subject to unethical medical research. Parents entrusted their children to these institutions and were assured that they were safe, only to be betrayed in the most shocking way. I cannot imagine the suffering that these families have endured. I found the descriptions in the section on people’s experiences deeply moving.

I recognise that an apology also means very little without action: without tangible plans for improvement. I hope that, over the course of this debate, I will be able to provide some reassurance to the community, and to your Lordships, that the Government have listened: that actions are being taken to ensure that nothing like this will ever happen again.

The inquiry’s findings are incredibly distressing to read and I thank Sir Brian for the unflinching honesty with which he delivers them in his report. The report states that

“what happened would not have happened if safety of the patient had been paramount throughout”.

This is a consistent theme throughout the report and remains apparent as the scandal evolved and different threats emerged. Patient safety consistently took a back seat to a variety of operational and reputational challenges for the Government. Indeed, Sir Brian’s report notes that, during the emergence of AIDS, the safety of the blood supply should have been the central focus. It should disturb all of us in your Lordships’ House that this was not the case.

The conclusions in the report of a cover-up driven by those in positions of power are sobering for us all. Individuals put their own self-interest before the safety of those they were supposed to serve. Sir Brian’s findings on the Government’s actions, and what he described as the “defensive culture” that led to many of the decisions that precipitated this scandal, are important to discuss. Indeed, Sir Brian highlights

“the consequences of civil servants and ministers adopting lines to take without sufficient reflection, when they were inaccurate, partial when they should have been qualified, had no proper evidential foundation … or made unrealistic claims that treatment had been the best it could be”.

A crucial example of this is the use of the phrase “no conclusive proof”. In volume 1 of the inquiry, we read that the first use of “no conclusive proof” appears in a line to take drafted for the then Prime Minister in 1983:

“It is important to put this in perspective: there is as yet no conclusive proof that AIDS has been transmitted from American blood products”.


The accompanying briefing note included the sentence:

“As yet there is no conclusive proof that AIDS is transmitted by blood as well as by homosexual contact but the evidence is suggestive that this is likely to be the case”.


Throughout the period of increased parliamentary and media scrutiny in 1983-84, this caveat was omitted. As Sir Brian states in his report:

“This line to take, whilst technically correct, was indefensible. It did not spell out the real risk. It gave false reassurance. It lacked candour and by not telling the whole truth was misleading … No minister challenged the ‘no conclusive proof’ line”.


His words paint a disturbing picture of a Government and a state more worried about the abundance of the blood supply than about the safety of the blood supply. There is a wealth of evidence uncovered by Sir Brian that points to the same thing: a state more focused on protecting itself than on protecting its people. This is utterly unacceptable.

I will move on to discussing Sir Brian’s recommendations and the progress we have made, but I stress that, in doing so, I do not want to minimise in any way the report’s findings. It is impossible to find the words that capture the severity and gravity of what is described in the report. It is incumbent on all of us to do what we can to provide justice to those impacted and ensure that no such disaster and scandal can ever be allowed to occur again.

I turn now to the 12 recommendations the inquiry makes in its report. The recommendations are wide-ranging and still being given full consideration by the Government. The Minister for the Cabinet Office will update Parliament on the progress made on considering and implementing each of the recommendations by the end of the year. I will briefly touch on some of the recommendations now, but I know that noble Lords will draw out others in the debate.

First, progress is being made on compensation. Over £1 billion has already been paid out in interim compensation, and the Government will pay out interim payments of £100,000 to the estates of the deceased people who were infected with contaminated blood or blood products and have not yet been recognised. This reflects the agreement reached in this House under the Victims and Prisoners Act, and I pay tribute to the many noble Lords who supported this important work and continue to be advocates for the infected blood community.

I am also pleased that, on 23 August, the Government laid the necessary legislation to enable the Infected Blood Compensation Authority to begin making payments to people who are infected, both living and deceased. The Government expect the Infected Blood Compensation Authority to begin payments under these regulations by the end of this year, and the authority is doing everything possible to be fully ready to deliver payments to as many people as possible, as soon as possible. Further regulations will be required for people who are affected. However, this will not impact the Government’s intention for the Infected Blood Compensation Authority to start making payments to people who are affected in 2025.

This progress came following a considerable engagement exercise undertaken by Sir Robert Francis KC —the interim chair of the Infected Blood Compensation Authority—in June this year with members of the infected blood community. In August, Sir Robert’s report was published, alongside a final report from the Infected Blood Inquiry response expert group, and a detailed policy document from the Cabinet Office setting out the design of the scheme, including case studies with examples of how this would work in practice.

Secondly, this Government are prioritising patient safety to ensure that the NHS treats people with the high quality and safe care that they deserve. Repeated inquiries and investigations have highlighted significant issues with patient safety, and this has contributed to a deterioration in public confidence. This is something that we must address. The Secretary of State for Health has already been clear that we will not tolerate NHS whistleblowers being silenced. A culture of openness and honesty is vital for ensuring patient safety. We want and need NHS staff to have the confidence to speak out and come forward if they have concerns.

I am pleased to say that, on recommendation 5—

“Ending the defensive culture in the Civil Service and government”—


work is under way across government to ensure that we reflect fully on Sir Brian’s words. In the King’s Speech opening this Parliament, the Government set out their commitment to bringing forward legislation to introduce a duty of candour for public authorities and public servants. The Prime Minister confirmed at the Labour Party conference that legislation on a duty of candour will be delivered by this Government. He confirmed that the duty will apply to public authorities and public servants and will include criminal sanctions. Work continues on the scope of the Bill. I know that colleagues across the House will have strong views on this, and I welcome the opportunity to come together and debate the Government’s proposals when the Bill is introduced.

The 12th and final of Sir Brian’s recommendations relates to giving effect to the recommendations of his report. I acknowledge the criticism that has been made, both by parliamentarians and others, on the failure of Governments to give proper regard to the recommendations of previous statutory inquiries. The Government are determined to ensure that no such criticism can be levelled against the response to Sir Brian’s report. I am aware that the updates provided on progress in my statement are by no means exhaustive, nor do they cover the full breadth of the recommendations laid out by the inquiry. As I said, my right honourable friend the Minister for the Cabinet Office will set out in more detail the Government’s response to the recommendations in a Statement in the other place by the end of this year.

Finally, I thank noble Lords for their understanding on the need for quick progress on the first set of regulations, made possible via the “made affirmative” procedure. To remain in force, the regulations must be debated and approved by Parliament by 23 October. I look forward to discussing this important matter further. As I am sure all noble Lords can agree, it is critical that the Infected Blood Compensation Authority retains the legal powers needed to begin making payments as soon as possible, enabled by these regulations. I am aware of the interest that this topic holds across the House, and I will hold a drop-in session for all noble Lords who may have specific questions on the Government’s progress.

Let us be in no doubt as to the importance of the report’s findings. I reiterate my thanks once again to Sir Brian and his team and to all those who came forward to share their stories, no matter how painful. The report lays bare the failure of the British state and the institutions in which people place their trust—institutions, indeed, in which we ask people to place their trust. That failure leaves an indelible stain on our nation, a mark of shame upon each and every person who allowed it to be perpetuated. Nothing that I can do or we can say will right the wrongs done to those infected and affected by this scandal. The best that we can do is to read, to reflect and to honour the courage of those impacted by this scandal and take the necessary action to ensure that something of this nature is never allowed to happen again in our country. I beg to move.

--- Later in debate ---

[Baroness Twycross (Lab)]

I thank noble Lords for the hugely important points raised in this debate. If I do not cover questions that they raised, I will endeavour to write with further details and put the letter in the Library.

Hearing your Lordships’ contributions today is a stark reminder of the enormity of this scandal and the utterly shocking truths that the inquiry brought to light. I am clear, as the noble Earl, Lord Howe, alluded to, that there is consensus across your Lordships’ House on the extent of the failure, the need to ensure redress as far as it is ever possible and to make that through the compensation scheme as quickly as possible, and that apologies are worth absolutely nothing without action to ensure that nothing like this can happen again. That is easily said but over many years it has proved almost impossible to deliver. We must do this with humility, as the noble Earl, Lord Howe, said.

A number of noble Lords mentioned the delay to the inquiry taking place, and it clearly took too long. I note the role of the noble Baroness, Lady May, in calling the inquiry, without which we would not have the report we are debating today.

The personal testimony of many of your Lordships, including the noble Baroness, Lady Featherstone, reflects the many tragic stories told in the inquiry’s report, as did the description by my noble friend Lord Jones of his discussions and contact with his constituent’s sons, which I found quite distressing, and the description from the noble Baroness, Lady Brinton, of her own engagement with the children at Treloar School. I am clear that no amount of money could possibly compensate both those infected or affected.

I will not repeat the points that the noble Earl, Lord Howe, made on the review of the noble Lord, Lord Darzi, apart from to thank him for seeing the relevance of the review to what the report outlines, not least in how we need to remedy the faults in the health system. It is clear that the government response to so many of the failures described in the report, including the emerging threat of AIDS in blood and blood products, should have been faster and better. Today, although no medical treatment can be completely risk free, current safety standards for blood donation and transfusion are rigorous, and England’s blood supply is one of the safest in the world. Throughout the blood donation journey, there are now processes in place to ensure the safety of blood and blood products. These include the donation safety check form, testing for specific infections, donor deferrals, regulations and informed consent. I noted with concern the points that the noble Baroness, Lady Brinton, made on blood transfusions, and will write to her on the points she raised and place a copy in the Library.

In response to the noble Baroness’s points on finding the undiagnosed, I can say that GP services have introduced a new case-finding question for patients registering with a new practice to locate people who received a blood transfusion prior to 1996.

In response to the noble Baroness’s point on the resources available for the Patient Safety Commissioner to do their job properly, I point out that we have today published the terms of reference for a review by Dr Penny Dash that will look at the patient safety landscape. This review will cover the office of the Patient Safety Commissioner, along with other organisations, and will help us to understand what is required to have effective national leadership on patient safety.

In response to the point from the noble Baroness, Lady Featherstone, on the moral obligation to compensate victims, I agree that a failure to deliver compensation for those infected and affected by the infected blood scandal would be a moral failure, and it is not one that this Government intend to commit.

On the level of funding made available to the infected blood support schemes, the Government are committed to ensuring that compensation is paid swiftly, not least because the victims of the scandal have already suffered unspeakably and for far too long. Noble Lords are right to raise the fact that, prior to the setting up of the support schemes in 2017, the previous approach of providing assistance was not effective. We can be in no doubt that everyone should have paid more regard to the victims of this scandal and sought to establish the truth for them much earlier. The time it took for the truth to come to light is unacceptable.

The right reverend Prelate and the noble Baroness, Lady Bennett, raised the Orgreave inquiry. Although that is not the main topic of this debate, I confirm to noble Lords that this was a manifesto commitment of the Labour Party during the election campaign, so it will happen.

The noble Lord, Lord Dobbs, referred to the countless examples of other occasions where the system becomes self-serving. However, I am not sure that I agree that a return to a past establishment that served the public better would serve the public best, because I am not sure that that is ever what an establishment does unless it receives the appropriate challenge required.

Both the noble Lord, Lord Bichard, and the noble Baroness, Lady Bennett, highlighted the risk of complacency. We cannot afford to be complacent, and the noble Baronesses, Lady Bennett and Lady Brinton, rightly highlighted the importance of asking questions. In response to the noble Lord, Lord Lansley, I say that I have no doubt of the good intention of Ministers, but the lesson I take as a new Minister is the need to ask questions, and the right questions at the right time.

One of the most shocking elements of the whole scandal—one of many—was the destruction of key documents, including ministerial advice and medical records. Records of any sort should not have been destroyed. Today, the Department of Health and Social Care employs robust document management procedures, with all its registered files under the direct control of its departmental records office.

A number of noble Lords, including the noble Lord, Lord Bichard, focused on process and what needs to change as a result of the findings. He noted the honesty and transparency already required. We rightly say that nothing like this should ever happen again, but these words are meaningless without a clear way forward. The Prime Minister’s announcement that legislation on a duty of candour will be introduced by the Government is one step towards ensuring that change will happen. The duty will apply to public authorities and public servants and will include criminal sanctions. Culture and behaviours also need to change, alongside thought being given to the way in which inquiries function and how the findings of inquiries are addressed.

I note the reservations of the noble Earl, Lord Howe, on the duty of candour, and look forward to future discussion on how we can make sure that this might be effective, not just for the current period but in future as well.

The noble Lord, Lord Bichard, and the right reverend Prelate the Bishop of Sheffield asked what will be the scope of the Bill on the duty of candour—as noted, it is otherwise known as the Hillsborough Bill—and what the Government consider a wide application for how it would be introduced. It will be introduced to Parliament before the next anniversary of the Hillsborough disaster. Following the Prime Minister’s announcement, its scope and policy detail continue to be worked through, and the Government will provide more detail at the end of the year. The Bill will set out the duties on public authorities and public servants, including any consequences for breaches, and that will include criminal offences.

The noble Lord, Lord Dobbs, asked how many civil servants had been disciplined and whether charges had been brought. That is for the police and the Crown Prosecution Service, who will look at these matters very carefully. However, should they take any such matters further, the Government will co-operate fully. I will ask a question on discipline issues, which is a separate matter, and will write to the noble Lord.

I found the contribution of the noble Baroness, Lady Berridge, very interesting. I welcomed her focus on the important role of public inquiries as a measure that is required and used when things go wrong; as a sign that the system is working when things fail, rather than a sign of failure itself. I do not have answers to all the noble Baroness’s questions, but I will endeavour to write on those I cannot answer today. Noble Lords will have already noted the report that the noble Baroness mentioned, published by the Statutory Inquiries Committee on 16 September, which made recommendations on the efficacy and practice of public inquiries. The Government are carefully considering these recommendations, as well as those of other public inquiries, and will respond in detail as soon as possible.

On the question raised by the noble Baroness, Lady Berridge, and a number of other noble Lords—I apologise for not mentioning them by name—concerning the role of Parliament in monitoring what happens after a public inquiry, the Government are looking closely at the recommendations made by the House of Lords inquiry and will respond by 16 November. As someone who has paid close attention to a number of public inquiries relating to some of my previous roles, for me, if we do not find a way of monitoring things carefully, we cannot give an assurance that we will prevent future harm or some of the issues we have seen in the past.

The noble Baroness, Lady Featherstone, asked about the autonomy and social impact awards we have made available for the affected. A social impact award for past and future consequences of the infection, including stigma and social isolation, will be awarded to people who were infected or their estate, and to affected persons. An autonomy award addressing the distress and suffering caused by the impact of the disease, including interference with family and private lives, will be awarded to people who were infected or their estate, and to affected partners, parents and children.

On which affected persons will be eligible for compensation, affected persons will be eligible where their case is linked to that of a person with an eligible infection under the compensation scheme, and is not dependent on whether the affected person had a financial dependency on the person with an infection. This includes affected partners, children, parents, siblings and other friends and family who cared for loved ones with an infection without reward or remuneration. So far, over £1 billion has been paid out in interim compensation payments to victims of the infected blood scandal. This month, applications will open for interim payments of £100,000 to the estates of deceased people who were registered with an infected blood support scheme or predecessor Alliance House organisation, and who were infected with contaminated blood or blood products and whose deaths have not yet been recognised.

The right reverend Prelate the Bishop of Sheffield and a number of other noble Lords, including my noble friend Lady Keeley, raised concerns about the timescale for compensation. I am conscious that the community wants further assurance on this. The Government expect the Infected Blood Compensation Authority to begin making payments under the infected blood compensation scheme to people who were infected by the end of this year. Payments to the affected are expected to begin in 2025 following a second set of regulations.

I understand the disappointment about the regulations being split out. There are important details—especially in consideration of Sir Robert Francis’s recommendations, the majority of which the Government have accepted—that must be worked through ahead of the second set of regulations. This includes details such as eligibility criteria for people who were affected, and an additional autonomy award for those who were the subjects of unethical testing.

In answer to the noble Baronesses, Lady Berridge and Lady Featherstone, and my noble friend Lady Keeley, who asked about the timing of payments to those affected, subject to parliamentary approval the Government are aiming for the second set of regulations to be in place by 31 March next year. This will support our intention that payments to affected people begin in 2025.

My noble friend Lady Keeley asked about interim payments to estates and whether there will be funding for legal help in obtaining probate. The Government will provide more information on the process of applying for interim payments to estates by the end of this month. We recognise the importance of legal support for applicants who need to obtain probate and will ensure that information is provided when applications open.

I hope that what I have said in summing up the debate has offered some reassurances to noble Lords, even if I have not managed to answer all the questions. As I said, a further update will be provided at the end of the year, but I am very happy to meet noble Lords to discuss details in the meantime. If I have not addressed certain specific points, I will ensure that I go back over them when I read through Hansard. As the noble Earl, Lord Howe, said, in some sense this is the start of a process, not the end. It is an incredibly important topic and I thank noble Lords for the time and scrutiny they have given it today. All noble Lords must be acutely aware of the responsibility we all have to ensure that we learn from the truly shocking events described in Sir Brian’s report. I assure your Lordships that the Government take the report extremely seriously and will continue to respond to these vital recommendations.

Motion agreed.