Nurses failed patients during infected blood scandal, inquiry finds | Nursing Times

The findings of an inquiry into the UK’s contaminated blood scandal were published this week, which laid bare failings of the “worst treatment disaster in the history of the NHS”.

“Tens of thousands of people put their trust in the care they got from the NHS over many years, and they were badly let down”

Amanda Pritchard

The Infected Blood Inquiry, led by former High Court judge Sir Brian Langstaff, examined why men, women and children across the UK were given infected blood and infected blood products in the NHS in the 1970s, 1980s and 1990s.

During those decades, people with bleeding disorders like haemophilia and those needing blood transfusions following an accident or during childbirth and surgery, were given blood with viruses in, including HIV and hepatitis C.

It is thought that more than 3,000 people have died because of the scandal, and it is estimated that an infected person still dies every four days as a result.

The report said: “It is important not to lose sight of the fact that behind those statistics are individuals, each with a story of suffering and loss that is personal to them.

“People infected and affected have told powerful stories of pain, sickness and loss, of lives damaged and destroyed, unrecognisable from before their infection and unrecognisable from all their hopes and dreams for their lives.”

The 2,527-page report by Sir Brian identified a “catalogue” of systemic, collective and individual failures to deal ethically, appropriately and quickly with the infections before, during and after they happened.

He placed particular blame on successive UK governments and the NHS for their inaction throughout the period and beyond.

In response to the inquiry findings, prime minister Rishi Sunak said it was a “day of shame for the British state”.

Speaking on the day of the report’s release, he said: “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 government, 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.”

The Infected Blood Inquiry report outlined key failures by clinicians, including nurses, which caused infected blood to be given to patients and inappropriate treatment to be given.

Evidence submitted to the inquiry by those who were infected through blood transfusions “consistently shows that patients were not warned of the risks of infection to inform their decision about whether or not to have a transfusion”, it warned.

In cases where a transfusion was a necessity, patients did not receive proper information about the risks involved.

One woman, who received blood following post-natal haemorrhages and miscarriages and subsequently was infected with hepatitis C, said: “I was never told that there was a risk of being infected with anything when I was given the blood transfusions.

“It was just a case of being told the nurse was coming to give me blood and that was it. There was no explanation.”

The report found that blood transfusions were “generally presented as beneficial” by clinicians without any reference to risks.

One woman received a transfusion in 1987 before she had a caesarean section, and then contracted hepatitis C.

She said: “When the nurse was putting the transfusion up, I asked her if the blood was OK, and she said yes, it was fine and told me it had been treated with gamma rays.”

In addition, nurses were among those who failed to offer people “reasonable alternatives to treatment or transfusions” when they requested them.

One woman was advised to have a blood transfusion after giving birth in 1984, the report explained.

When she refused and said, “No I don’t want someone else’s blood in my body”, the nurse at the time said she would get better more quickly if she had a transfusion.

The following day, she was found “crying in bed whilst being transfused”.

She was infected with HIV which was transmitted to her infant son. She died in 1995 and her son died in 2007.

Meanwhile, Sarah Akoni, a nurse whose husband had sickle cell anaemia, described how he had to have blood transfusions regularly due to his chronic condition.

Ms Akoni said she did not believe her husband was told of the risk of contamination from blood during the late 1980s.

While she was training to be a nurse in 1992, she said nurses still “didn’t gain consent or talk about contaminated blood when giving blood transfusions, only the risk of having a reaction to the blood”.

Concerningly, the inquiry found that, in far too many cases, clinicians used “insensitive and inappropriate means” to tell people of their infections.

One patient, referred to in the report as Mr AH, who contracted HIV and hepatitis C from blood products as a child, was initially told he was HIV positive by a play specialist at the hospital, instead of a registered doctor or nurse.

“I didn’t know what to think, I was shocked and disturbed,” he said.

“I was 12 years old. I couldn’t process that information correctly.”

“On behalf of this and every government stretching back to the 1970s, I am truly sorry”

Rishi Sunak

A few years later Mr AH was in hospital being treated for an AIDS-related illness and a nurse came to his bedside and told him he also had hepatitis C.

“The nurse went on to say that I shouldn’t worry too much about it because I wouldn’t be affected by it for around 12 years,” he explained.

“She then left me on my own, no one was present with me in the room not even my parents were with me.”

The report also found that many patients who were attending hospital for pre-existing conditions were not told they were being tested for hepatitis C.

One woman, who has a blood disorder called beta thalassaemia major and requires very regular transfusions, remembered asking the nurses why they were taking more blood than usual at one of her appointments.

“Instead of two bottles they would take five, so I am sure they were testing without my knowing what for,” she explained.

“I remember asking the nurses and they would just say the doctor needs it.”

Despite nurses’ complicity in the failings identified in the report, the inquiry noted the positive role that specialist nurses played in treating infected patients.

Several participants to the inquiry said they were “very positive” about the difference specialist nurses had made.

After being diagnosed with hepatitis C virus (HCV), Christine Simpson said she was assigned a “very nice and very helpful” specialist nurse.

She said: “HCV was her specialism and she really knew her stuff. She gave me a lot of information regarding HCV.”

Meanwhile, Imelda Stephenson said that her specialist nurse Katherine was “absolutely amazing”.

“She always kept me informed and was able to tell if I was having a good or bad day,” said Ms Stephenson.

“She would calm me down if I came to them in tears.”

Sir Brian put forward several recommendations to ensure the errors identified in the inquiry are not repeated, and a scandal like this never happens again.

The principal recommendation was that a compensation scheme should be set up for all those infected.

As such, the government announced today that it would pay “comprehensive compensation” to those impacted by the infected blood scandal.

Victims of the scandal are set to receive £210,000 as an interim compensation payment from as early as this summer.

Another recommendation called on all those responsible for the scandal to issue public apologies, and for there to be a national memorial to remember those lives lost.

Sir Brian also called for a change in NHS culture “such that safety is embedded as a first principal”.

In his speech delivered in the House of Commons, the prime minister apologised for the failures identified in the inquiry.

“It did not have to be this way, it should never have been this way, and on behalf of this and every government stretching back to the 1970s, I am truly sorry,” said Mr Sunak.

He argued that there was “no moving on from a report that is so devastating in its criticisms”.

As such, he promised that the government would study Sir Brian’s recommendations “in detail” before returning to parliament for a full response.

Meanwhile, NHS England chief executive Amanda Pritchard said the inquiry report followed “a long fight for answers and understanding” that those who were infected and their families “should never have had to face”.

She said: “What is already very clear is that tens of thousands of people put their trust in the care they got from the NHS over many years, and they were badly let down.

“I therefore offer my deepest and heartfelt apologies for the role the NHS played in the suffering and the loss of all those infected and affected.

“I know that the apologies I can offer now do not begin to do justice to the scale of personal tragedy set out in this report, but we are committed to demonstrating this in our actions as we respond to its recommendations.”