Infected Blood Inquiry Report

Rishi Sunak Excerpts

Monday 20th May 2024 Commons Chamber

[The Prime Minister (Rishi Sunak)]

Mr Speaker, Sir Brian Langstaff has today published the final report of the infected blood inquiry. This is a day of shame for the British state. Today’s report shows a decades-long moral failure at the heart of our national life. From the national health service to the civil service, to Ministers in successive Governments, at every level the people and institutions in which we place our trust failed in the most harrowing and devastating way. They failed the victims and their families, and they failed this country.

Sir Brian finds a “catalogue” of systemic, collective, and individual failures, each on its own serious, and taken together amounting to “a calamity”. The result of this inquiry should shake our nation to its core. This should have been avoided. It was known that these treatments were contaminated. Warnings were ignored, repeatedly. Time and again, people in positions of power and trust had the chance to stop the transmission of those infections. Time and again, they failed to do so.

Sir Brian finds “an attitude of denial” towards the risks of treatment. Worse, to our eternal shame, and in a way that is hard even to comprehend, they allowed victims to become “objects for research”. Many, including children at Lord Mayor Treloar College, were part of trials, conducted without their or their parents’ knowledge or consent. Those with haemophilia or bleeding disorders were infected with HIV, hepatitis C and hepatitis B through NHS treatment, through blood clotting products such as factor 8, including those who had been misdiagnosed and did not even require treatment. Many were infected through whole blood transfusions. Others were infected through their partners and loved ones, often after diagnoses had been deliberately withheld for months or even years, meaning that these infections should easily have been prevented.

I find it almost impossible to comprehend how it must have felt to be told that you had been infected, through no fault of your own, with HIV, hepatitis B or hepatitis C; or to face the grief of losing a child; or to be a young child and lose your mum or dad. Many of those infected went on to develop horrific conditions, including cirrhosis, liver cancer, pneumonia, TB and AIDS, and to endure debilitating treatments, such as interferon, for these illnesses —illnesses the NHS had given them.

Many were treated disdainfully by healthcare professionals, who made appalling assumptions about the origin of their infections. Worse still, they were made to think that they were imagining it. They were made to feel stupid. They felt abandoned by the NHS that had infected them. Those who acquired HIV endured social rejection, vilification and abuse at a time when society understood so little about the emerging epidemic of AIDS. With illness came the indignity of financial hardship, including for carers, those widowed and other bereaved family members.

Throughout it all, victims and their loved ones have had to fight for justice, fight to be heard, fight to be believed and fight to uncover the full truth. Some had their medical records withheld or even destroyed. The inquiry finds that some Government papers were destroyed in

“a deliberate attempt to make the truth more difficult to reveal.”

Sir Brian explicitly asks the question: “Was there a cover-up?” Let me directly quote his answer for the House: “there has been”. He continues:

“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.”

More than 3,000 people died without that truth. They died without an apology. They died without knowing how and why this was allowed to happen. And they died without seeing anyone held to account.

Today, I want to speak directly to the victims and their families, some of whom are with us in the Gallery. I want to make a wholehearted and unequivocal apology for this terrible injustice. First, I want to apologise for the failure in blood policy and blood products, and the devastating—and so often fatal—impact that had on so many lives, including the impact of treatments that were known or proved to be contaminated; the failure to respond to the risk of imported concentrates; the failure to prioritise self-sufficiency in blood; the failure to introduce screening services sooner; and the mismanagement of the response to the emergence of AIDS and hepatitis viruses among infected blood victims.

Secondly, I want to apologise for the repeated failure of the state and our medical professionals to recognise the harm caused. That includes the failure of previous payments schemes, the inadequate levels of funding made available, and the failure to recognise hepatitis B victims.

Thirdly, I want to apologise for the institutional refusal to face up to these failings—and worse, the denial and even the attempt to cover them up—the dismissing of reports and campaigners’ detailed representations; the loss and destruction of key documents, including ministerial advice and medical records; and the appalling length of time it took to secure the public inquiry that has delivered the full truth today.

There is layer upon layer of hurt, endured across decades. This is an apology from the state to every single person impacted by this scandal. It did not have to be this way. It should never have been this way. On behalf of this and every Government stretching back to the 1970s, I am truly sorry.

Today is a day for the victims and their families to hear the full truth acknowledged by all and, in the full presence of that truth, to remember the many, many lost loved ones. But justice also demands action and accountability, so I make two solemn promises. First, we will pay comprehensive compensation to those infected and those affected by this scandal, accepting the principles recommended by the inquiry, which builds on the work of Sir Robert Francis. Whatever it costs to deliver the scheme, we will pay it. My right hon. Friend the Minister for the Cabinet Office will set out the details tomorrow.

Secondly, it is not enough to say sorry, pay long-overdue compensation and then attempt to move on. There can be no moving on from a report that is so devastating in its criticisms. Of course, in some areas medical practice has long since evolved, and no one is questioning that every day our NHS provides amazing and lifesaving care to the British people. But Sir Brian and his team have made wide-ranging recommendations. We will study them in detail before returning to the House with a full response. We must fundamentally rebalance the system so that we finally address the pattern, so familiar from other inquiries such as Hillsborough, where innocent victims have to fight for decades just to be believed.

The whole House will join me in thanking Sir Brian and his team, especially for keeping the infected blood community at the heart of their work. We would not be here today without those who tirelessly fought for justice for so many years. I include journalists and parliamentarians in both Houses, especially the right hon. Member for Kingston upon Hull North (Dame Diana Johnson), but most of all, the victims and their families. Many of them have dedicated their lives to leading charities and campaign groups, pouring their own money into decades of running helplines, archiving, researching and pursuing legal cases, often in the face of appalling prejudice. It is impossible to capture the full pain and injustice that they have faced. Their sorrow has been unimaginable. They have watched loved ones die, cared for them as they suffered excruciating treatments, or provided their palliative care. Many families were broken up by the strain. Hundreds of thousands of lives have been knocked off course; dreams and

potential unfulfilled.

But today, their voices have finally been heard. The full truth stands for all to see. We will work together across Government, our health services and civil society to ensure that nothing like this can ever happen in our country again. I commend this statement to the House.

[Mr Speaker]

I call the Leader of the Opposition.

[Keir Starmer (Holborn and St Pancras) (Lab)]

This response can begin in only one place, because this is an injustice that has spanned across Governments on an unprecedented scale, and collectively we failed to protect some of the most vulnerable in our country. So as well as paying tribute to the courage and determination of the victims—the infected and the affected—some of whom are in the Gallery today, I want to acknowledge to every single person who has suffered that, in addition to all the other failings, politics itself failed you. That failure applies to all parties, including my own. There is only one word: sorry.

By that apology, I acknowledge that that suffering was caused by wrongdoing, delay and systemic failure across the board, compounded by institutional defensiveness. As Sir Brian Langstaff makes clear in his report, any apology today must be accompanied by action, so I welcome the Prime Minister’s confirmation that compensation will now be paid. He should be under do doubt whatsoever that we will work with him to get that done swiftly, because—make no mistake—the victims in this scandal have suffered unspeakably. Thousands of people have died; they continue to die every week. Lives completely shattered; evidence wilfully destroyed; victims marginalised; people watching their loved ones die; children used as objects of research—on and on it goes. The pain is barely conceivable. As well as an apology, I want to make clear that we commit to shine a harsh light upon the lessons that must be learned to make sure that nothing like this ever happens again.

Passing through the doors of a hospital is a moment of profound vulnerability; you entrust your life into the hands of perfect strangers. We go to hospital for care. That is what many of the people affected find so hard to accept—the betrayal of that trust by people and institutions that were meant to protect them. People like my constituent Mark Stewart, who was given factor VIII in the 1980s as part of a clinical trial, as were his father and his brother. All three subsequently contracted hepatitis C, but only Mark remains with us today.

Over the decades as Mark and so many like him searched for truth and justice, the British state ignored them. The truth, as Sir Brian says today, was hidden from them for decades. That is why this is one of the gravest injustices this country has seen. Yet, we have to be honest: this scandal is not unique. The institutional defensiveness identified by Sir Brian is a pattern of behaviour that we must address. Mark may never get his brother, his father or his health back, but for all the families affected we must restore the sense that this is a country that can rectify injustice, particularly when carried out by institutes of the state. That is our job today, this week and beyond. Frankly, it is the very least that we owe.

[The Prime Minister]

I thank the right hon. and learned Gentleman for the collegiate tone in which he has responded to today’s report, and for his sincerity. He is right that it is irrefutably clear that an unconscionable injustice has been done—the result of a consistent and systemic failure by the state time and again, decade after decade. That is why I apologise wholeheartedly and unequivocally to every single person impacted by the scandal. The anger and sorrow felt across this House is the right response. It is right that we now act on behalf of the victims, their loved ones and the whole community, who expect us to put right this historic wrong.

[Mr Speaker]

I call the Father of the House.

[Sir Peter Bottomley (Worthing West) (Con)]

The thousands of people at Central Hall thanked Sir Brian Langstaff, and he thanked them. As has been said, we should acknowledge the right hon. Member for Kingston upon Hull North (Dame Diana Johnson) and her leadership of the all-party group.

Permanent secretaries and Cabinet Secretaries need to say to everyone throughout their chain, “Are we doing something that is right? Are we doing something that is necessary? Are we doing something that will work?” Does my right hon. Friend agree that if those questions had been asked more effectively, the number of tragedies would have been not five for every MP—and five times again for everyone injured or affected—but greatly reduced, and that we would have learned the truth earlier?

[The Prime Minister]

Let me start by thanking my hon. Friend for his dedicated work co-chairing the all-party parliamentary group on haemophilia and contaminated blood, alongside the right hon. Member for Kingston upon Hull North (Dame Diana Johnson). I assure him that Sir Brian’s report is highly detailed and sets out a number of recommendations, and that we will respond to it in full as quickly as possible.

[Mr Speaker]

I call the SNP leader.

[Stephen Flynn (Aberdeen South) (SNP)]

I wish to begin by stating something I think we all now agree is self-evidently the case, which is that this scandal represents the very worst of Westminster: decades of deflection, decades of denial and, of course, decades of deceit; children used as research; parents watching their children die; children watching their parents die; and tens of thousands of people impacted, many of whom are not here to see this day. For those who imposed this tragedy upon them, no consequences have yet been felt. But today is not about them.

Today is about the victims, and I say to them, on behalf of myself and my colleagues in the Scottish National party on these Benches: I wish to offer you three things. The first is an apology. I am incredibly sorry that this happened to you. The second is to say, quite openly, thank you; thank you for your determination and your desire—for being able to pry open the doors of this place and ensure that your voices were heard by all of us. We would not be here today without your efforts. The third is to say to the victims: I can assure you that we will do everything we can to ensure that the Government implement the recommendations, as laid out today.

We have heard the Prime Minister make a very sincere promise in relation to compensation; and we will work with him and his Government, and indeed any future Government, to ensure that that promise is swiftly kept.

[The Prime Minister]

I welcome the absolute consensus that today is a moment for the families and the community, and for their voices to be heard loudest. Every single testimony and account in Sir Brian’s report today sets out a unique story of hurt, suffering and loss. Individually, these accounts are astounding; taken together, they are truly unimaginable. They must be heard and they must be understood, as the right hon. Gentleman said. I thank him for his remarks. I know that we share a determination to work together to ensure that nothing like this shocking and avoidable calamity can ever happen in our country again.

[Mrs Theresa May (Maidenhead) (Con)]

Sir Brian Langstaff’s report today has finally uncovered the truth of this appalling tragedy, which has affected the lives of so many. So many have been fighting, as the Prime Minister and the Leader of the Opposition said, for decades to get to this point. Sir Brian has highlighted a devastating and abject failure of the British state: medical professionals, civil servants and politicians, all of whom felt their job was to protect their own reputation rather than to serve and look after the public they were there to serve. Today, as we rightly remember all the victims of this terrible tragedy, will my right hon. Friend commit himself unashamedly to working to ensure that all those in Government—politicians and civil servants—recognise that their job is to serve the public, not to protect themselves?

[The Prime Minister]

I thank my right hon. Friend for her statement. As Prime Minister, she launched Sir Brian’s inquiry and in doing so began the process of establishing the full truth we have heard today. There is no doubt, as she recognises, that the inquiry came too late, that the compensation came too late and was woefully insufficient, and that the consequences of that failure are stark. That is why today I apologise on behalf of Governments since the 1970s for that shameful failure.

Sir Brian and his team have made a series of wide-ranging recommendations, and I can assure my right hon. Friend that we will study every single one in detail and work urgently across Government and public organisations—our health services, civil society, all—to ensure that nothing like this can ever happen again, and that we end the challenges she encountered, where the institutions responsible for serving the public, including the NHS and the civil service, are more concerned by cost than accountability.

[Ed Davey (Kingston and Surbiton) (LD)]

Today is about the tens of thousands of people whose lives have been torn apart by this disaster. Many of them have fought and waited for decades to see this day, and, tragically—as the Prime Minister reminded us—thousands have died waiting. I pay tribute to the survivors, the families, the campaigners and the journalists who have fought so long and so hard for justice. Having listened to their stories and having now seen the evidence laid bare in this report, I want, on behalf of my party, to echo the Prime Minister’s apology. We are all truly sorry for the pain that people have suffered over decades, under Governments of all parties, and for the failures of politicians and the state to do the most fundamental job: to keep people safe. We must now ensure that full compensation is paid without any more delay, and that nothing like this can ever happen again.

In his report, Sir Brian highlights the fact that

“the truth has been hidden for decades”

through a

“lack of openness, transparency and candour”

which has caused enormous damage. Will the Prime Minister join me in backing the survivors’ call for a duty of candour on all public officials?

[The Prime Minister]

I thank the right hon. Gentleman for what he has said. Across this House, we share a determination to work together to ensure that nothing comparable to this shocking and avoidable tragedy can happen ever again in our country. Today is a day for the victims and their families to hear the full truth, unequivocally acknowledged by all, and to remember the many, many lost loved ones. As I have said, my right hon. Friend the Minister for the Cabinet Office will make a full statement tomorrow, but we will study every one of Sir Brian’s recommendations in detail and work urgently across all parts of civil society to ensure that innocent victims are never again forced to fight for decades to be believed.

[Sir Sajid Javid (Bromsgrove) (Con)]

I welcome my right hon. Friend’s statement, and, indeed, the words of the Leader of the Opposition.

This scandal—the biggest in the history of the NHS—along with the scandals of the Mid Staffordshire NHS Foundation Trust and those covered by the Ockenden and Cass reviews, are linked by public servants putting their reputations and that of the NHS above patient safety and care. Time and again, Ministers—including me—have stood at that Dispatch Box under successive Governments, promising that lessons will be learnt. I ask my right hon. Friend: why will it be any different this time?

[The Prime Minister]

Sir Brian’s report states categorically that this scandal represents a decades-long moral failure of the state, but in particular he highlights an appalling truth: that our national health service failed. It was known that blood and blood products given by medical professionals were contaminated. It is correct to acknowledge that medical practice has evolved—every day hundreds of thousands of our NHS staff do provide life-saving care for the British people, and we are incredibly grateful—but the report sets out clear and wide-ranging recommendations that we must study closely, and we will work urgently with our health services to ensure that nothing like this will ever happen again.

[Dame Diana Johnson (Kingston upon Hull North) (Lab)]

I thank the Prime Minister for his statement, and for his apology on behalf of the nation. I also thank Sir Brian for his report. Finally—the truth. It is a vindication of nearly 50 years of campaigning for justice. I pay tribute to all those infected and affected, and also, importantly, to those who have lost their lives in the biggest treatment disaster in the history of the NHS. Two people, on average, are still dying every week. I wonder whether the Prime Minister understands that, although his Government accepted the moral case for compensation to be paid in December 2022, their failure to act on Sir Brian’s second interim report in April 2023 has added another layer of hurt. I hope very much, following what the Prime Minister has said this afternoon, that by the end of this year compensation payments will start to be made to all those infected and affected.

[The Prime Minister]

I thank the right hon. Lady for her statement, and for her care and unwavering dedication to delivering justice. She knows better than anyone in the House the devastation that this scandal has inflicted on the community, and the strength they have shown in their fight for the truth. Sir Brian’s report sets out a decades-long failure and makes it clear that this is a moment of national shame. No one could fail to be moved by the stories within it, by the utterly shameful treatment of victims and their loved ones, by the callousness and cruelty that they suffered, and by their outstanding bravery, resilience and refusal to yield to a lifetime of prejudice and trauma. They have fought for the truth to be out, and they were right. Above all, today is a day for their voices to be heard.

[Mr Speaker]

That completes this short statement. There will be a full statement tomorrow, when all the details of compensation will be brought to the House and all Members will be able to get in.