Langstaff says he intends to hold government to account to ensure recommendations are implemented
Langstaff said he wanted to ensure his recommendations were implemented.
He said that, in his letter to John Glen, the Cabinet Office minister handling the inquiry, he said that he was not yet able to say the inquiry had fulfilled its term of reference in terms of the “nature, adequacy and timeliness” of its conclusion
The reference to “timeliness” provoked a round of applause.
He said that he wanted to ensure the recommendations of the report were not allowed to “collect dust on the Cabinet Office shelf are realised”. He said he would do everything in his power to stop that happening.
In his report he says that he expects the government to say, before the end of the year, what progress it is making on implementing his recommendation. He says that, until that happens, he will not accept that he has fulfilled his terms of reference (ie, that the inquiry process is over).
UPDATE: Langstaff said:
In the context of this inquiry, perhaps beyond all other, it is unconscionable to allow a state of affairs to exist in which people’s fears that the lessons and recommendations of this inquiry will collect dust on a Cabinet Office shelf are realised …
It is for the government to respond as it will, but I intend to use my position as far as I properly can to prevent unreasonable delay in its doing so.
Key events
YouGov has published some polling on Westminster voting intention in Scotland suggesting that the resignation of Humza Yousaf has coincided with Labour opening up a wide lead over the SNP.
Rob Ford, a politics professor and elections expert, says a lead of this kind, if sustained,
Will need a few more polls to see whether this is an outlier but, if it holds, this kind of lead gets Labour into the territory where they flip a *lot* of SNP seats https://t.co/oxIPJrFufp
— Rob Ford (@robfordmancs) May 20, 2024
Will need a few more polls to see whether this is an outlier but, if it holds, this kind of lead gets Labour into the territory where they flip a *lot* of SNP seats
Changes from GE 2019:
Lab 39 (+20)
SNP 29 (-16)This would be an 18 point national swing. Maybe higher in SNP-Lab marginals. Every SNP seat with a majority over Labour of less than 40 points would be vulnerable. That is…almost every SNP seat pic.twitter.com/wweViVPlMV
— Rob Ford (@robfordmancs) May 20, 2024
Changes from GE 2019:
Lab 39 (+20)
SNP 29 (-16)This would be an 18 point national swing. Maybe higher in SNP-Lab marginals. Every SNP seat with a majority over Labour of less than 40 points would be vulnerable. That is…almost every SNP seat
I did a substack piece early last year looking at seats that could be vulnerable if SNP fell back after Nicola Sturgeon’s departure. The largest SNP to Lab swing I looked at was 13 points – anything larger seemed implausible. Maybe not.
And here’s what I wrote in September of last year on why a sea change in Scotland could happen, with major consequences for the election result
Stephen Dorrell, who was health secretary from 1995 to 1997, told Times Radio that teh findings of the infected blood inquiry were “shaming to all of us who passed through the Department of Health”.
Echoing what has been said by Ed Davey and other former Post Office minister who now say they were misled about the Post Office Horizon scandal, Dorrell said that officials did not tell him the truth when he asked about the infected blood victims. He said”
In my time as health secretary, I was aware of the issue. We did indeed ask questions about how this tragedy came to happen and whether it was true that the care provided to these patients was the best available, complied with best practice at the time.
We were repeatedly told that that was true.
It wasn’t true and we clearly should have asked more effective questions to unearth the truth.
Dorrell also claimed that NHS was particularly bad at cover-ups. He explained:
The health service is a repeat offender, persuading itself that because it’s an organisation that has strong public support, therefore what it does is somehow the best that can be done and should be defended.
Where we need to learn, as people who care about the health service, is to be much more rigorous at questioning practices within the Health Service and being less willing to accept the proposition that this was the best we could have done at the time.
Langstaff ended his statement by referring to Perry Evans, who had haemophilia, and was infected with HIV in the 1980s, and he gave evidence to the inquiry on the first day it opened. He had been able to lead an active life. But he died five weeks ago, Langstaff said.
He said justice, recognition and compensation may too too late for Evans, but it is not too late for other people to get them.
UPDATE: Langstaff said:
It may be late, but it is not too late: now is the time, finally, for national recognition of this disaster, for proper compensation and for vindication for all those have been so terribly wronged.
Langstaff says he intends to hold government to account to ensure recommendations are implemented
Langstaff said he wanted to ensure his recommendations were implemented.
He said that, in his letter to John Glen, the Cabinet Office minister handling the inquiry, he said that he was not yet able to say the inquiry had fulfilled its term of reference in terms of the “nature, adequacy and timeliness” of its conclusion
The reference to “timeliness” provoked a round of applause.
He said that he wanted to ensure the recommendations of the report were not allowed to “collect dust on the Cabinet Office shelf are realised”. He said he would do everything in his power to stop that happening.
In his report he says that he expects the government to say, before the end of the year, what progress it is making on implementing his recommendation. He says that, until that happens, he will not accept that he has fulfilled his terms of reference (ie, that the inquiry process is over).
UPDATE: Langstaff said:
In the context of this inquiry, perhaps beyond all other, it is unconscionable to allow a state of affairs to exist in which people’s fears that the lessons and recommendations of this inquiry will collect dust on a Cabinet Office shelf are realised …
It is for the government to respond as it will, but I intend to use my position as far as I properly can to prevent unreasonable delay in its doing so.
Langstaff proposes new rule to make it harder for government to avoid holding public inquiries when they’re needed
Langstaff said that he was making recommendatons to empower the patient voice, and to improve patient advocacy.
He said he also wanted to ensure that it is harder for the government to avoid holding an inquiry when one is needed.
He said that he was recommending that, if the Commons public administration and constitututional affairs committee says a public inquiry should take place, the government should have to give a statement explaining in detail why it disagreed.
Langstaff implicitly criticises government for ignoring his recommendation last year on compensation
Langstaff says he expects the government to apologise. He goes on:
To be meaningful, though, that apology must explain what the apology is for.
It should recognise and acknowledge not just the suffering, but the fact that the suffering was the result of errors, wrongs done and delays incurred. It should provide vindication to those who have waited for that for so long.
And it should be accompanied by action.
Action, obviously to recognise and remember what happened to so many people and to learn for the inquiry. Action to implement recommendations I made over a year ago to set up a proper compensation scheme.
That sounded like a rebuke. The government always said it would not announce a compensation scheme until the final report was out, but Langstaff said it should start work earlier.
There have been suspicions that ministers were dragging their feet partly on cost grounds.
Langstaff says some official documents were deliberately destroyed to cover up infected blood scandal
Langstaff says he has not been able to find some of the documents he wanted to look at.
In some cases, it is not clear why they have disappeared, he says.
But in other cases he says he has concluded “they were deliberately and wrongly destroyed in an attempt to make the truth more difficult to reveal”.
How civil servant complained about health minister whose sympathy for victims was ‘uppermost in his mind’
Langstaff says 23 countries introduced screening for blood products before the UK did.
He says the government told patients they were getting the best available treatment, and that screening for blood was not available, when both those things were untrue.
And he says much of the blame for this “institutional defensiveness” lies with the civil service.
He says some of what was said by civil servants could have come from a Yes Minister script. As an example, he quotes from this note written by an official in the Department of Health in the 1990s when John Horam, a new minister, expressed an interest in the case for paying compensation to people with haemophilia given infected blood. The official wrote:
The permanent secretary may wish to be aware of the attached minute. I mentioned to him the other day that PS (H) [Parliamentary Under-Secretary of State for Health] was clearly not happy with the firm line ministers have taken up to now on compensation for haemophiliacs infected with hepatitis C. It is quite clear that he is trying to change the line, little by little. He has had plenty of briefing (written and oral) on the subject, but his sympathy for those concerned is clearly uppermost in his mind. Cost comes second – hence his readiness to consider proposals for a scheme limited to those who have actually developed chronic illness, rather than extending to all who have been infected.
UPDATE: Langstaff said:
The failures in decision-making that led to the original infections were then compounded by institutional defensiveness.
This pattern of institutional defensiveness must stop. When citizens have concerns that something has gone seriously wrong, fairness should mean they get answers …
Much of the responsibility for this institutional defensiveness lies with the civil service.
Langstaff criticised the way children were used as objects for research. (See 1.17pm.)
As an example of the health profession failing to take the risk from infected blood seriously, Langstaff refers to Prof Arthur Bloom, a Welsh specialist in haemophilia, who is now dead. Here is an extract from what Langstaff said about Bloom in the report.
Concern about AIDS became more widespread when the BBC screened a Horizon programme which identified “the 4 Hs” in the major risk groups – “Homosexual males, IV Drug (Heroin) users, Haitians and Haemophiliacs” on 25 April 1983. There were also reports in the mainstream press at the start of May 1983, notably an article by Susan Douglas in The Mail on Sunday on 1 May, with the banner headline “Hospitals using killer blood”. She reported an epidemiologist as saying “It seems madness that our blood supplies are coming from a country suffering from an epidemic”.
Despite this, and despite having reported to the CDSC on 26 April a probable case of AIDS in a young man with haemophilia treated at the Cardiff Haemophilia Centre, on 4 May 1983 a statement from Professor Bloom was sent to Haemophilia Society members saying that the “cause of AIDS is quite unknown and it has not been proven to result from transmission of a specific infective agent in blood products”, that the number of AIDS cases was small and that “in spite of inaccurate statements in the press” he was unaware of any proven case in “our own haemophilic population”. Professor Bloom advised no change to therapy with factor concentrates.
Professor Bloom may have been saying one thing for public consumption, whilst advocating a different tack within his own haemophilia centre …
If what Professor Bloom had said had been faithful to the facts, and he had advised the Haemophilia Society that there was a real risk that taking factor concentrates risked contracting AIDS, and that the likelihood of the risk becoming a certainty appeared to be growing stronger by the month, it is not difficult to see that the events that followed might have taken a different turn.
Langstaff says around 1,250 people with bleeding disorders were infected with HIV. Three quarters of them died, he says.
He says that number is roughly equivalent to the number of people in Westminster Central Hall. To bring home how many people died, he asks people in the audience to imagine only a quarter of them being there.
Langstaff says the use of surrogate testing could have reduced the risk. But he says there was a four-year delay in the UK before it was introduced.
He says a test for HIV was developed in August 1984. But it was not used to screen blood donations until October 1985, he says.
UPDATE: Longstaff said:
In the case of HIV, a test had been developed by August 1984 but was not introduced for the screening of blood donations until October 1985.
I have concluded that we lost months, for no clear reason, by delays and indecision when setting up a process to evaluate each available make of 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 a screening test was available, and approved, its use had to wait till all regions could introduce it on the same date – in other words, to go at the pace of the slowest.
When the government claimed that screening for hepatitis C had been introduced as soon as the technology became available, they ignored the long list of countries that introduced screening before the UK.
Langstaff said that the risk of infection from blood transfusions were known at least from the 1940s.
He quotes various pieces of evidence from health officials confirming this, including one person saying in 1946 that blood was a “potentially lethal fluid”.
And people knew that the risk was dependent on who the donors were, he says. The government knew there was a risk of collected blood from people in prison because of the increased danger from hepatitis. But that continued until 1984, he says.
He says in the UK people give blood voluntarily. But in the US people are paid to donate, and that is known to increase the risk of people with an infection donating, he says.
Despite this risk, in the 1970s the UK allowed the importation of blood products from America. That was wrong, he says.
Langstaff says ‘this disaster was not an accident’
Langstaff says: “This disaster was not an accident.”
That generates a round of applause.
He says inquiries normally have a backward-looking aspect, into what happened, and a forward-looking one, into what should happen next.
But this one has had a third element: how did the government respond.
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 that testing of blood donations began as soon as the technology was available, and both claims were untrue.
He says that means it is important for the inquiry to ensure that in future people are not treated like this, and that the government responds “in a way which reflects the true facts”.
Langstaff says the report was handed to the Cabinet Office at 7am, and shown to campaigners, under embargo, from 8am.
He says there are seven volumes, with “quite a lot of detail”.
But he sums it up like 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.
He says he could not adequately put into words what people suffered. Parents had to watch their children die, he says. And children watched their parents die.
He says the trauma continues to this day.
And he says in the past treatments for HIV and hepatitis C were often worse than the illness itself.
The side effects linger for a number of those infected with hepatitis C. The damage down over so many years to the liver has left them at risk of developing cancer, requiring liver transplants.
Every aspect of their lives have been defined by their infections – childhood education, career, leisure relationships marriages homeownership, travel, finances, dreams. Ambitions have been lost, relationships broken.