Was a disaster not an accident, that those in authority, doctors, Blood Services and governments did not put Patient Safety first and that patients were knowingly exposed to unacceptable risks of infection. Andy evans has haemophilia, a Bleeding Disorder. He is one of 30,000 people infected by the treatment he received. By the time he was five years old he had hiv and hepatitis c, and at 13 he had developed full blown aids. No, if that is for me of my remarkable team, thank you. Applause. But you are actually applauding the wrong people. This is your report. Aim i may have done the words, certainly the errors and omissions are all mine. 0ne certainly the errors and omissions are all mine. One of them has already been pointed out to me this morning by one of you. But the words can from you and your stories. I want you please in a moment to give me an applause at least as long and probably longer, standing if you would if you can, to those who are really responsible for what is in this report. Look to your right, look to your left, looking front, those of you who can look behind. Those are the people who have written this report all for your very different perspectives. Applause. That is where the material comes from. You. At 7am this morning my full report was handed to the Cabinet Office to be given to the minister and at atm of it was made available to most of you here. It is now my role to present it to you and to the wider public who have watched this from home or on live stream and the wider public who have had no connection with the inquiry before. Well, here it is. Seven volumes. There is quite a lot of detail in it. What it comes to is 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. For everyone involved the evidence given to this inquiry has been difficult to this inquiry has been difficult to listen to. That is the wrong word. Its hard for those centrally involved. It must have been hard for many observing. But it has been much harder still for those who are recounting their own experiences or listening to stories which touched a nerve, which brought back memories they would rather have forgotten, but which they brought themselves to tell the inquiry because the truth was important to tell. The harm that was important to tell. The harm that was done to people cannot adequately be put into words. I have tried. The patients and parents watching the children suffer and in many cases die, children witnessed the decline in the death of one and sometimes both parents and their lives were altered as a result. People had to care for the egregiously all partners or other Family Members often at the expense of their own health and careers. Early on in particular they had to do so whilst being shunned or worse abused by neighbours, workmates, by people they once thought of as friends. Sometimes even by health professionals. The inquiry is not just investigating something that happened years ago, it is still happening. People still have to care for the after effects of what their loved ones still suffer. The grief, the trauma which all of those lost loved ones experienced continues to this day. The early treatments for hiv and hepatitis c were often worse than the illnesses themselves. The side effects linger and for a number of those infected with hepatitis c the damage done over so many years to their liver is left them at risk of delivering cancer and requirement requiring liver transplants. Every aspect of their lives have been defined by the infections. Childhood, education, career, leisure, relationships, marriages, homeownership, travel, finances. Dreams and ambitions have been lost, relationships broken. True though each of those consequences is, it really takes a person who has lived and is living with them to describe them in a way which brings home the full horror of what had happened. And that is why in this report i have tried to record peoples experiences in some detail where i can using the wrong words. They are better than mine. Those experiences have been central to this inquiry� s work and must be central to the response to this report. But i could not record every individual story in this report. I hope the thousands of statements which speak to people suffering and endurance which will remain accessible on the Inquiry Website along with the transcripts and recordings of the oral evidence will ensure that their voices and their pain are never forgotten. Will ensure that their voices and their pain are neverforgotten. And will move future listeners and readers as they have moved so many during this inquiry. This disaster must was not an accident. Applause people put their faith people put theirfaith in people put their faith in doctors and in the government to keep them safe and their trust was betrayed. There are generally two elements to any major public inquiry, and backward looking at what happened and why and the other forward looking and on what next and how do we stop it happening again. This inquiry is different. There is a third element to this inquiry� s terms of references. What was the response of government and others in authority to what had happened . Here, 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 the testing of Blood Donations began as soon as the technology was available and both claims were untrue. Applause. That means that part of the work next and how do we stop it happening again is not only taking steps to meet any threat of future infection carried by blood, Blood Products or tissue, but how to ensure as far as we can that the government response to the citizens it serves, how shall i put this, more appropriately, in a way that reflects the true flats facts. To turn back to what the report says about why infections happened on such a scale over such a time to so many people, the picture is a complex one and the feelings were multiple. First, government Blood Services, doctors, new at least 80 years ago since the mid i9 40s that blood could transmit hepatitis and that this was a significant disease which could lead to cirrhosis, liverfailure, liver cancer and death. This was not something kept to the dusty libraries of academic knowledge. The Consultant Adviser on Blood Transfusion to the Chief Medical Officer wrote in 1916 that users of plasma must be told that it is a potentially lethal fluid which should be used with discretion. In 1964 circular from the scottish home and Health Department said no transfusion should be undertaken unless the benefits outweigh the risks of hepatitis. One of the leading Transfusion Directors used to write On The Boards for students, blood can kill. The risk was not limited to hepatitis but it included the risks of future unknown viruses. In the light of that knowledge you might expect action to be taken to reduce the risks which were known of the kenai to be kept on if new risk started to emerge. What happened was not that. Tragically, the infections happened because those in authority, doctors, the Blood Services and successive governments, did not put Patient Safety first. They lost sight of what was known about the risks of viral infections from blood. Doctor knows was such a strong belief that Health Departments did not issue guidance to curb the unsafe use of blood and Blood Products. Decision making on measures which couldnt make blood and Blood Products are safer was put off and then dragged out unnecessarily and failed to reach clear and decisive conclusions. And patients were not given the information they needed to make fully informed decisions about their own treatments. As long ago as 1952 the World Health Organization identified how to reduce the risks of Transmitting Hepatitis through blood and Blood Products. Uk medical and government adviser took a central part in this. There were four key measures highlighted by the World Health Organization on which despite its involvement in identifying them the uk fell short. The first was the selection of donors, the second was restricting the size of the pool is used to make Plasma Products, the food was treating Plasma Products to reduce infection and the fourth maintaining good records and reporting infections. Each of these is addressed in detail in the report that i shall say a little more about some aspects of each of them now. The key point is that if we had followed the World Health Organizations advice they would have been fewer infections from blood and Blood Products and fewer deaths. As to the selection of donors, everyone who received blood or products made from blood plasma depended on the quality of the donations which ended up in their veins. That depended on donors. Knowing your donor and the risks that might come with their blood is fundamental to any system of Collecting Blood. The blood used for transfusions and to make Blood Products in the uk was from british donors who could and should have been better selected. For instance, in 1975 the Chief Medical Officer for england said the practice of Collecting Blood in prisons could continue, even though prisoners were known to have higher numbers of hepatitis infections. This practice was not ended in the uk until 1984. For instance, no real efforts were made to prevent those who used intravenous drugs and with a four at a higher risk of hepatitis from donating blood. And for instance, the steps taken to keep donors who were more likely to be Incubating Aids Out of the chain were late in starting. And when they finally began were inadequate. As for pool sizes the dangers of pulling plasma from many donors were established by the medical Research Council in 1944. The greater the number of donors to pull the greater the risk from it because one infected donation could contaminate the hopeful. In 1951 the textbook that was then the bible of Blood Transfusion said the use of large pool plasma has of course been abandoned. The use of only small pools lasted until after 1970 but then however something extraordinary happened. Just as the long term seriousness of hepatitis began became more and more apparent, the size of pools used to make uk Blood Products grew ever larger and larger. And with that so to did the risk. Instead of reducing the risk, the uk was steadily increasing it. Blood donors in the uk gave blood freely purely for the good of other people unknown to them and they deserve praise for that. By contrast, the blood supplied in the us was largely sold by people who needed the money. The hepatitis that gave rise to and the number of deaths that followed resulted in the us Authorities Banning Sales of whole blood for transfusion in 1973. At the us authorities did not stop people selling their plasma to Pharmaceutical Companies to be made into Blood Products. In 1973 the uk Licensing Authority gave the green light to the importation and distribution of an american Blood Product and an austrian Blood Product and an austrian Blood Product also made using paid donations. Despite the manufacturers making no secrets of the risks of hepatitis they posed. The Licensing Authority knew of the risks from sales of blood plasma from people who did not inspire confidence. And were motivated by money. The Licensing Authority new to that these products were made from very large pools. The risks of hepatitis were freely admitted by the makers. I have concluded that the uk was wrong to decide to license these products in 1973 and later decisions in the 1970s to grant further licences were also wrong. Those products simply should not have been permitted to be distributed generally in this country. Despite the World Health Organizations reminder in 1952 of the importance of Record Keeping, poor Record Keeping has been a problem across many of the issues examined by the inquiry. This had an impact on safety. If you cant trace the source of those transfusions back to the donor was infected you cannot then tell and treat the donor and avoid any further donations from that source, nor can you trace previous donations to check if other people who have had transfusions from the same source have then become ill and reporting infections did not have the priority should have done. For instance, at the height of the aids crisis the north london Blood Transfusion Centre had to ask the Government Committee responsible for aids three times to arrange for the Chief Medical Officer to ask doctors to find out if Aids Patients had previously donated blood. As well as the more rigorous selection of donors and until such time as direct tests specific to hepatitis c and hiv were available, a further way of reducing the chances that hepatitis c or hiv would get into the blood supply and be transfused was to test for certain markers in the blood which could help identify the donations that might be infected. This was known as Silica Testing. The opportunity of the Silica Testing in the case of hiv was lost and in respect of Hepatitis C Taking a decision about it was put off, put off and then delayed until it was simply too late. One doctor involved rightly described the process as going round in very small circles some distance away from the target. Nearly four years were lost, during which the risks could have been very significantly reduced. The government was to claim in the 1990s that the direct tests for these viruses were introduced as soon as the technology was available. That was wrong. In the cases of each of the viruses. In the case of hiv the test had been developed by august 1984. But it was not introduced for the screening of Blood Donations until october 1985. The screening of Blood Donations until october1985. It the screening of Blood Donations until october 1985. It takes time to produce such a test in sufficient quantity to screen all Blood Donations and to check its reliability, but i have concluded that we lost months for no clear reason by delays and indecision while setting up the process to evaluate every available make up test. Yet a number were commercially available and being used elsewhere in the world. Patients receiving transfusions in the uk were needlessly exposed to the risk of hiv as a result. In the case of hepatitis c the delays were even worse. Screening of Blood Donations was not introduced until September 1991. Even when the Screening Test was available not all regions could introduce it on the same date. Where the government claimed that screening for hepatitis c had been reintroduced as soon as the technology became available, they ignored the long list of countries that introduced screening before the uk. Japan, australia, france, luxembourg, finland, the us, austria, the netherlands, canada, germany, belgium, switzerland, italy. Shall i go on . Spain, norway, sweden, portugal, cyprus, greece, hungary, iceland, malta and denmark. 23. Just because the Department Of Health hoped what they said was true didnt mean to say it was. You might have thought that as soon as the Screening Test for hepatitis c was introduced across the board in September 1991 donors who were infected and might not have realised it could be identified and told. And that anybody had previously been given suspect blood could be traced and checked. You would have been wrong. It took around four years for there to be a general look back like this. When transfusion director thought this was so unethical that he arranged to conduct look back in his area but he had to call it a pilot study but he wanted to do it and did it. His work deserves praise. It was instrumental in the uk look back being delayed no further than it was but the delay which had already occurred made to look back less successful than it would and should have been. Hepatitis c tests concerned hepatitis obviously, almost everyone who had a severe Bleeding Disorder had hepatitis as a result. But 1250 people with Bleeding Disorders were also infected with hiv. Nearly one third of those infected with hiv were children. Three quarters of those who have hiv have died. These are figures, their numbers, percentages, they are difficult to relate to. But look around you. The number of you who are filling The Street Will Today is roughly the same as number of people who had Bleeding Disorders who were infected with hiv. Picture back. And now picture only a quarter of you being here. A number of failures contributed to the infection of so many with Bleeding Disorders. Failing to plan, sufficient. Failure to achieve Self Sufficiency which then became Government Policy was not delivered until the end of the 1980s. Failing to suspend imports in may 1983. Continuing importations of products made from plasma connected before Safety Measures were adopted the usa, and being slow to adopt and develop heat treated Blood Products in which hiv had been inactivated and neutralised. A real risk of Blood Products transmitted the cause of aids was known by government injuly 1982. It was known by all Haemophilia Doctors by the end of 1982. There was already a growing epidemic in the us likely to come to these shores yet the response you was one of denial, disbelief, dismissive this and delay. The governments response was slow. So too was the response of Haemophilia Centre directors and of their organisation the uk h ceo. Professor arthur blum was chairman of the Haemophilia Directors untied many years ago. He must pay some of the responsibility for the uks slowness in responding to the risks of aids to people with haemophilia. In may 1983 the Mail On Sunday put hospitals using killer blood on the front page. We in the inquiry now believe that one of the sources for that story was professor blooms respected senior colleague in cardiff who was reluctant at the time to be identified as a whistle blower. Professor bloom told the Haemophilia Society that inspired or inaccurate statements in the press, he was in the press, he was unaware of any proven case in the uk and there was no need to change the treatment. Haemophilia society related his advice to the members. Yet he himself was treating a patient he believed had aids. He reported as much to the uk centre for disease surveillance. He was a member of the various committees involved in the response to aids and disastrously the Department Of Health and Social Security was over influenced by his advice, in particular his advice to continue Importing Commercialfactor importing commercial factor concentrates when Importing Commercialfactor concentrates when the leader. Had advised against it. Inexplicably, no Government Minister was shown the epidemiological advice to suspend imports until the risk of aids was better understood. The decision taken injuly1983 not to suspend them was a bad one for a number of reasons. One was the idea that the risk of aids was out balanced by the benefits of using the products because it was said in the products because it was said in the case of haemophilia it was life saving. That ignored both the fact that most treatments for people with haemophilia were not used in life threatening situations and the fact that there were tried and trusted life saving alternatives. In particular, much less risky cryoprecipitate, each unit of which was produced from a single donation by a british voluntary donor. Another reason it was a bad decision was the conclusion it wasnt feasible to replace concentrates with Cryoprecipitate On Grounds of supply. Yet Transfusion Directors told the inquiry that if asked, they could have made more of the Cryoprecipitate Treatment for people with Bleeding Disorders