The long-awaited report into the infected blood scandal detailed how tens of thousands of people were let down by the NHS and other institutions after placing their trust in them.
More than 30,000 people became infected with HIV and hepatitis C while receiving NHS care between the 1970s and 1990s in biggest treatment scandal in NHS history.
While the health service is at the center of the issue, it is not the only organization to take the blame for contributing to around 3,000 deaths of people who received infected blood products.
Also accused of being guilty is Treloar School, a school in Hampshire for disabled children and young people, which provided specialist treatment for boys with haemophilia. These boys would then be used as “research objects”, according to the inquiry reportwith “very few who escaped the infection”.
Between 1970 and 1987, several boarding school students received treatment for haemophilia at a local NHS center whilst receiving their education, but it was later discovered that many with the disease had been treated with plasma blood products infected with hepatitis and HIV. .
The report highlights the “consternation and distress” caused in many cases when GPs, receptionists, nurses and even directors and pharmaceutical companies were informed of diagnoses before the patients themselves.
Students sent back to class after being told they have HIV
One particularly chilling detail in the 2,527-page report is how some students were gathered into “groups of five” and told “you have it, you don’t have it” as staff revealed to them whether they were infected with a deadly disease.
The fact that these boys were told to return to school rather than return home to their parents or a counselor is described in the report as “appalling”.
It condemns the conduct of the late Dr. Anthony Aronstam, former director of the school’s hemophilia center, who allegedly “minimized the risks of both hepatitis and AIDS.”
“There was no consistent practice of telling individuals that they had been infected with HIV,” the report continues. “Some were never informed by the school and were only informed by their doctor at home. Others were informed in groups.”
He details how staff walked around the room saying “yes, no, yes, no” to indicate who was HIV positive, adding that if children were first told at school that they had tested positive, their parents were not present and there was no “structured facility” of support thereafter, adding that there was “very little evidence of professional psychological counselling”.
Only 30 of 122 students with hemophilia survived
“A large percentage (probably around 70%) of students with haemophilia who attended Treloar School died as a result of the infection,” the report says.
“Of those who were students in the early 1980s, the vast majority were infected with HIV; and very few, whether HIV-positive or not, avoided becoming infected with hepatitis.”
The few surviving alumni included in trials held at the school gave a “consistent report” that the increased risks of the blood products they received were “not explained” and that there was “no meaningful consultation” with or with their parents.
Students treated as ‘research subjects’
The report highlights how boys at the school – then known as Lord Mayor Treloar College – were treated as “research subjects”, whose safety and well-being were placed behind the results sought by doctors.
He states that research was a “fundamental part” of the hemophilia center’s activities, for reasons that “were not difficult to understand”.
As Dr. Rosemary Biggs, a central figure in the treatment of hemophilia, noted: “The collection of 49 hemophiliac patients” at the school presented a “unique opportunity to study the disease.”
The research at Treloar – which merged with a girls’ school in 1978 to become co-educational – was “unparalleled elsewhere” – but the report says “informed consent to participation was neither sought nor given”.
Boys at the school were unnecessarily treated with various commercial concentrates that were known to pose higher risks of infection, rather than being offered safer alternative treatments.
Among the products tested was Factor 8, a medicine extracted from blood plasma, much of which was imported from the US and made from blood purchased from prisoners, drug users, sex workers and other high-risk groups.
The report, written by inquiry chair Sir Brian Langstaff, concluded there was “no doubt” that healthcare professionals at Treloar were aware of the risks of contracting viruses from these products.
Sir Brian adds: “Not only was it a prerequisite for research, a key aspect of Treloar, but knowledge of the risks is demonstrated in what doctors wrote at the time.
“Students were often considered as objects of investigation and not, first and foremost, as children whose treatment should be firmly focused solely on their individual best interests. This was unethical and wrong.”
School hopes grieving families can find solace
In a statement released on Monday, Rishi Sunak issued an “unconditional and unequivocal” apology to victims of the biggest NHS treatment disaster, promising that “comprehensive” compensation will be delivered “whatever the cost”.
The school boys were just one example of the thousands of victims who received contaminated blood, with the report alleging there was a “chilling” cover-up, with evidence from Department of Health documents marked for destruction in 1993.
In a statement, Treloar School and College said the report “shows the full extent of this terrible national scandal” while revealing the “systemic failure” at its heart.
“We are devastated that some of our former students have been so tragically affected and we hope the findings provide some solace to them and their families.”
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