The UK's infected blood scandal that has killed 3,000 people and left thousands more suffering with hepatitis or HIV must lead to an end to the UK's "paternalistic culture" where reputations matter more than justice.
That is the blunt demand by Kate Burt, Chief Executive of the Haemophilia Society, to Monday's publication of the long-awaited report by inquiry chair Brian Langstaff.
The report came amid ongoing accusations against the UK government of a similar cover-up regarding the country's Post Office scandal in which hundreds of post office managers across Britain were wrongly accused - and in some cases convicted - of theft and fraud because of a computer hiccup.
As outlined in the Infected Blood Inquiry, more than 30,000 people received infected blood and blood products in the 1970s and 1980s from Britain's state-funded National Health Service, destroying lives, dreams and families.
Burt told CGTN: "The only way that a repetition of such a disaster can be avoided is if there is a major change to the way the institutions of power, including government, the civil service and institutions like the National Health Service interact with the people that they are here to serve.
"We have a paternalistic culture in the UK that has got to change, and the fact that saving reputations and saving money, rather than saving lives, was seen as more important has to change. It's a moment where the culture of the UK has to shift."
The use of infected blood, despite the known risks, has resulted in thousands of victims in the United States, France, Canada and other countries, in part after U.S. prisoners and other high-risk groups were paid to provide blood.
In Britain around 1,250 people with bleeding disorders were infected with HIV, including about 380 children, the inquiry found. Three quarters of them died.
According to Burt: "Six thousand people with hemophilia and bleeding disorders were infected. Many more members of the public were infected through blood transfusions in hospitals. People are dying every week. Parents lost children, children lost parents, husbands, wives. People died in the most horrible of circumstances and through all of that time, the government was telling us that no wrong had been done. Yesterday that was proved to be a lie."
"This disaster was not an accident," inquiry chief Langstaff told the media on Monday. "The infections happened because those in authority - doctors, the blood services and successive governments - did not put patient safety first."
He said proper compensation must now be paid.
Burt said the public were shocked to hear of the full details of the scandal but "everybody in the hemophilia and bleeding disorder community have known for four decades that wrong was done and that it was covered up, so we weren't shocked."
People impacted by the contaminated blood scandal gather in Westminster for a vigil to remember those that lost their lives ahead of the report's release. /Hollie Adams/Reuters
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The inquiry, which started in 2018 and does not have the power to recommend prosecutions, blamed a catalogue of failures by government and doctors.
As Burt explained: "In the 1970s we were not self-sufficient in the domestic blood and blood product supply. The World Health Organization had already issued warnings about the creation of plasma pools that they should be limited to at most 20 donors.
"However, the UK government took the decision to start importing blood products from overseas and mainly from the United States of America, which had a dangerously unregulated donation system where they were paying people to donate their blood, targeting prisons in Louisiana and Arkansas and pooling plasma from tens of thousands of donors."
She added: "All it would take is one donor to have a virus, such as hepatitis or HIV, for the entire pool to be contaminated. People with hemophilia and bleeding disorders need to have infusions maybe one or two times a week to help their blood clot, so essentially we were importing poisoned blood and giving it to people with hemophilia and other bleeding disorders and condemning them to almost certain infection."
The UK government, which in 2015 said it was "something that never should have happened," agreed in 2022 to pay an interim $125,000 to those affected. There are reports that the eventual compensation bill could top $15 billion.
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