“The government failed to discharge its fundamental duty to ensure the safety of the public” is the damning conclusion from the infected blood report.
And those failures span decades, under Labour and Conservative governments, starting in the mid-1970s when the Department of Health ignored the dangers of contracting hepatitis from blood transfusions collected in prisons.
But the calamity worsened when HIV emerged in the early 1980s. By 1982, medical journals were saying the danger of passing on the infection through blood products was real. But it was only after newspapers started reporting the issue in May 1983 that the Department of Health paid attention.
We now know that officials knew that it was “very likely to be true” that HIV could be transmitted in this way. Despite that, ministers, including Ken Clarke, the health secretary, continued to insist that there was “no conclusive proof”. The report says that false reassurance was “indefensible” and “misleading”.
For decades after that, ministers and even prime ministers insisted, wrongly, that the victims had been given the best care available. They refused to allow a public inquiry, partly through fear of having to pay compensation.
The report says that continued failure to examine what went wrong “cannot be easily excused”. Theresa May finally relented in 2017, but only after she had lost her majority at the general election, so could no longer resist.