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It was the worst treatment disaster in the history of the NHS – a scandal characterised by "an attitude of denial" and a "lack of openness, transparency and candour" by the NHS and successive governments which included the "deliberate destruction of some documents and the loss of others".
In a vast-ranging report into the use of blood products contaminated with HIV and hepatitis during the 1970s and 80s, Sir Brian Langstaff criticised repeated breaches of patient safety and consent – including doctors testing patients for diseases without their knowledge, but failing to inform them of any subsequent diagnoses – and the fixation of officials on an absence of "conclusive proof" that tainted transfusions were sickening patients as justifiable grounds for doing nothing. Instead, they should have been "asking if there was a real risk" and taking precautions.
Had they done so at the earliest possible stage, the tragedy – which has so far claimed 3000 lives, many of them children – "could largely, though not entirely, have been avoided".
What have we learned about Scotland's role?
Alarm Bells
There were warnings that hepatitis could be spread via blood as early as December 1964, when a memo from the Scottish Home and Health Department (SHHD) noted that "all blood for transfusion must be regarded as potentially contaminated... no transfusion should be undertaken unless the benefits outweigh the risk of hepatitis".
In June 1982, the Second International Symposium on Infections in the Immunocompromised Host was held in Stirling, Scotland.
Dr Ian Hann, one of a handful of haematologists in attendance, told the inquiry he left realising that AIDS might be relevant to haemophilia patients, describing revelations from the conference as "a bombshell".
However, there was no serious discussion between Scottish health officials about the implications of AIDS for blood donation until May 24 1983, but – like the Department of Health in England – the reaction of the SHHD was "to do too little and to do it too late".
The report adds that: "Too much faith was placed in the safety of the domestic blood supply in Scotland because of the voluntary donor system."
Unlike other parts of the UK, Scotland was not reliant on US imports but it did accept donations from prisoners who are more likely to carry blood-borne infections due to intravenous drug use.
Donations were also pooled – in the case of one contaminated batch, from 4000 donors.
Research
Patients in Glasgow and Edinburgh, including children, were subject to research without their knowledge.
In the autumn of 1984, Professor Christopher Ludlam sent a number of stored samples for HIV and hepatitis testing without the knowledge or agreement of the patients concerned.
He was told the results in October, but "it was not until 1985 that the process began of informing individual patients of their test results".
The report adds: "Until then, some who were infected with HIV were not aware of the need to avoid infecting others; others continued to treat themselves with concentrates in the erroneous belief that [Protein Fractionation Centre] concentrates were entirely safe."
Meanwhile, at Yorkhill hospital in Glasgow – together with children's hospitals in Liverpool and Birmingham – commercial concentrates "were the mainstay of treatment".
Children were given American plasma products to treat haemophilia despite warnings that the imported concentrates were high risk. In total, 21 children at Yorkhill became infected with HIV at the hospital.
This was "utterly unacceptable", said Sir Brian: "It is plain also that most clinicians responsible for children with haemophilia did not pay sufficient regard to the dangers to their patients."
Exactly why clinicians – in Scotland and the rest of the UK – were persuaded to downplay or ignore the potential harms might be hinted at in one section of the report which describes how there were "regular, usually cordial, interactions between sales representatives of pharmaceutical companies and haemophilia centre clinicians" during the 1970s and 1980s.
Sometimes this extended to gifts, sometimes "sponsorship or funding for research", and sometimes "overwhelmingly lavish" hospitality at conferences, from meals in "the very best restaurants" to river cruises.
Why?: "Because they could gain influence with it."
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