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Sanjiv
Authorities covered up the infected-blood scandal after knowingly exposing victims to unacceptable risks, a long-awaited report says.
The five-year investigation accused doctors, government and the NHS of letting patients catch HIV and hepatitis.
More than 30,000 people were infected, from 1970 to 1991, by contaminated blood products and transfusions.
About 3,000 have since died and more deaths will follow.
The Infected Blood Inquiry said victims had been failed "not once but repeatedly" by doctors, the NHS, government and others responsible for their safety.
Patient safety had not been paramount in decision-making, it said, pointing out the risk of transmitting viral infections in blood and blood products had been known since the NHS's foundation, in 1948.
Despite this, people had been exposed to "unacceptable risks", including:
Sir Brian Langstaff, who chaired the inquiry, said the scale of the scandal was "horrifying" and the authorities had been too slow to respond to the risks.
Addressing the issue of a cover-up, he said better wording was "hiding the truth".
There had been a lack of openness, inquiry, accountability and elements of "downright deception", including destroying documents.
But hiding the truth included not only deliberate concealment but telling half-truths or not telling people what they had had a right to know - including the risks of treatment they had received, what alternatives had been available and, at times, even the fact they had been infected.
Sir Brian said the scandal had destroyed "lives, dreams, friendships, families and finances", adding the numbers dying were still climbing week by week.
"This disaster was not an accident," he said.
"The infections happened because those in authority - doctors, the blood services and successive governments - did not put patient safety first."
About 380 children with bleeding disorders had caught HIV after being given blood products for their condition, the report said.
Many had died in childhood or young adulthood, having endured a level of pain and fear no child or young person should ever have to face.
And some had been treated without them or their parents giving informed consent, which the report called unconscionable.
Sir Brian also criticised the delays to calling a public inquiry.
Then-Prime Minister Theresa May announced it in 2017, under political pressure.
That it had taken so long had hampered his investigation, Sir Brian said, as key people had since died or become too frail to give evidence.
And an "institutional defensiveness" by the NHS and government had compounded the harms done.
In particular, Sir Brian singled out Cardiff Haemophilia Centre director Prof Arthur Bloom, considered one the UK's leading haematologists in the 1970s and 80s, who died in 1992.
Prof Bloom's views, according to the report, "overly influenced" the way the government viewed the emergence of Aids (acquired immune deficiency syndrome) and played down the threat to people with bleeding disorders.
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