The 2,527 pages of Sir Brian Langstaff’s report make for deeply uncomfortable and difficult reading.
He warns in the summary to his damning document: “It will be astonishing to anyone who reads this report that these events could have happened in the UK.
“The wrongs were done on individual, collective and systemic levels.”
Infected blood scandal latest: Report into worst treatment disaster in NHS history published
For the victims and the families of the infected and affected by this scandal, this report is an absolute vindication of everything they have been saying for the last 40 or so years.
Patients – including many young children – were involved in secret trials and experiments, the clinicians involved knew about the risks, and when strong evidence began to emerge concerns were dismissed.
Families were continually gaslighted with a “doctor knows best” response.
This was at the beginning of the scandal, but what followed was decades of denial, with successive governments refusing to establish a public inquiry to avoid compensation payments.
Campaigners have been saying for years they are the victims of a cover-up. Nobody listened or took those claims seriously.
But now Sir Brian says the destruction of documents was “hiding the truth”.
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The Treloars school, rightly, earns its own mention in this report.
A specialist school that was supposed to treat haemophilic children instead became a laboratory where experiments could be carried out on children without them or their parents knowing.
Only 30 of 122 pupils with haemophilia who attended the school between 1970 and 1987 are still alive.
Read more:
The stories behind 100 victims
‘I gave my young son to his killers’
Infections are ‘worst thing you can imagine’
Dr Rosemary Biggs, one of the lead clinicians at the site at the time, is quoted as saying: “The collection of 49 haemophiliac patients at the school makes this a unique opportunity to study this disease.”
Sir Brian says: “The pupils were regarded as objects of research rather than children.”
He adds this was both “unethical” and “wrong”.
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The report concludes by saying this scandal could and should have been avoided. The victims and their families have been saying this all along.
Sir Brian Langstaff’s report has found they were right.