The victims of the tainted blood scandal have been denied justice for too long

Of all the scandals that have emerged to blacken this country’s reputation for justice and sound governance, the contaminated blood scandal can claim at once to be the longest running, to have affected the greatest number of people, and to have been the most grievously neglected. Some of that will finally change when the report of the public inquiry – set up, it should be noted, only in 2018 – is published on Monday.

At the same time, it has to be recognised that much – perhaps most – of the immense hurt caused and the damage done by what has been described as the worst treatment disaster in the history of the NHS can never be remedied, and that whatever financial compensation is recommended will be far too little, far too late. Official apologies and recognition of fault are one thing – and long overdue – but money remains the only currency in which recognition of fault can be paid.

As many as 3,000 people died as a direct result of receiving contaminated blood. Parents were deprived of their children. Children were left without parents. Hundreds were infected with HIV (Aids), and tens of thousands – perhaps hundreds of thousands – were infected with hepatitis C. The precise number is hard to establish, as the effects of hepatitis C may manifest themselves only after many years. As if the damage to health was not enough, individuals and whole families found themselves ostracised because of the stigma of blood-borne diseases such as Aids and HIV, for which there was then no treatment.

Many were haemophiliacs, for whom the blood-clotting agent known as factor 8 was a revolutionary treatment that made it possible to lead a relatively normal life. The other group were people who had received transfusions of blood, which turned out to be contaminated, as part of their medical treatment. The consequences of this are still emerging four decades on, as people come forward for tests and are found to have been infected with Aids or hepatitis C.

It should be acknowledged that when factor 8 first became available in the 1970s, it was a lifesaving and life-changing treatment for haemophiliacs, and the first of its kind. It was understandable that doctors and patients should clamour for what was seen by some as a miracle intervention. That could help to explain why there was a rush to try to obtain supplies of plasma from abroad, given the shortage at home, and why – as it has emerged – some young children were enrolled in what were essentially trials without their families being told.

It is in the subsequent four decades that the most egregious failings, as identified by the inquiry, are to be found – and they fall, essentially, into three categories. First, despite mounting evidence that batches of plasma bought from abroad (in particular from the United States) were contaminated, there was a reluctance to recognise this and take action. It is simply astonishing that the UK was still importing blood from the US when other countries had reduced or halted the practice, and that in the UK, people were still being infected through blood transfusions in the early 1990s, long after heat treatment for plasma had been proved to be effective. Why was the UK more dilatory in taking action than many other countries?

Second, there is the difficulty the inquiry experienced in establishing the facts, and in tracking responsibility. Some of that is a result of so many years’ delay – but by no means all. Crucial sections of records kept by the government and the NHS turned out to be missing – and they had not just been culled, it would appear, but deliberately destroyed. The UK system – wherein political accountability rests with ministers who are elected politicians, rather than with civil servants – may give an appearance of clarity, but, as has been seen time and again in the wake of such scandals, it can facilitate buck-passing and can muddy the process of establishing accountability.

It is not just apparently destroyed records and (sometimes conveniently) faded memories that leave blame hard to assign, but a degree of systemic confusion. A prime objective, both of those who have suffered directly and of the wider public, is to “get justice”, which means not just a payout – indeed, money is often not the central demand – but calling those responsible to account. As in this case, it can be hard to establish exactly where the blame lies. If lessons are to be learnt, then tracing the lines of responsibility is essential.

And a third issue is the decades-long delay in setting up an inquiry, or even considering compensation. Again, the UK was far behind many other countries, including France, Germany and Ireland, not just in trying to find out what had happened and why, but then in establishing a standardised system to deal with claims for recompense – whether in the form of monetary payments or special benefits – that recognised the long-term nature of the damage. Many of those affected by the UK’s contaminated blood scandal have as yet received no compensation at all, with quibbling still going on, as the inquiry recommendations were being finalised, as to which groups of survivors and bereaved families would qualify.

There should also be a broader consideration. The decades of delay in ordering the inquiry into the contaminated blood scandal may have set a record, but quarrels and delays about timing and terms have been a set piece of very many postmortems on the failings of government and other institutions – from Hillsborough to Grenfell Tower, and now the Post Office – as well as the unconscionable time they take when they finally get going.

Not for the first time, there are questions to be asked about whether such inquiries, in the way they are currently conceived, constitute the best mechanism for reaching judgments when aspects of the state fail, and for providing due recompense for those, such as the victims of the contaminated blood scandal, whose lives were lost or forever blighted as a result of what governments did or did not do.