A “catalog of failures” by government and medical officials in Britain, most of them avoidable errors, led to blood contaminations that killed about 3,000 people and infected more than 30,000 others over two decades, according to a long-awaited report published on Monday.
The report is the product of a six-year inquiry that the British government ordered in 2017 after decades of pressure from victims and their families, and it could pave the way for sizable compensation payments.
The independent report puts a harsh spotlight on Britain’s state-run National Health Service, identifying “systemic, collective and individual failures” by British authorities as they dealt with the infections of tens of thousands of people by tainted blood transfusions or contaminated blood products between the 1970s and the 1990s.
The authorities at the time refused to acknowledge those failings — including the lack of proper screening and testing of blood — by “hiding the truth,” the report said.
“This disaster was no accident,” Brian Langstaff, a former High Court judge who led the inquiry, said at a news conference on Monday. “People put their trust in doctors and the government to keep them safe, and that trust was betrayed.”
He added, “The N.H.S. and successive governments compounded the agony by refusing to accept that wrong had been done.”
In the summary of the 2,000-page report, Mr. Langstaff wrote that the inquiry had documented a “catalog of failures.”
“Each on its own is serious,” he wrote. “Taken together they are a calamity.” He said the problems “could largely, though not entirely, have been avoided.”
At the news conference in London, victims of the blood contamination and their families expressed relief over the report’s findings but also anger that it had taken so long. They said that it was now up to the British government to acknowledge its failures and to adequately compensate the victims.
Andy Evans, a longtime campaigner who was 13 when he discovered that a blood transfusion for his hemophilia had given him H.I.V., said that he felt “validated and vindicated.”
“We’ve been gaslit for generations,” Mr. Evans said. “This report puts an end to that.”
Prime Minister Rishi Sunak of Britain was expected on Monday to deliver an official government apology before Parliament for the failures, many of which occurred before Mr. Sunak was even born. The British government had agreed in 2022 to distribute to each victim an interim payment of 100,000 pounds, or about $127,000.
The inquiry did not have the authority to recommend criminal prosecutions, and it was not immediately clear whether the report would lead to any.
“If there’s clear evidence and there is a pathway to that, then it’s obviously something the government will have to address,” John Glen, the British government official who has been in charge of matters related to the infected blood inquiry, told LBC radio on Monday.
“I can’t be sure, but we’ve got to give these people justice,” Mr. Glen said.
The scandal has its roots in the 1970s and 1980s, when thousands of patients were exposed to the contaminated blood. Some required blood transfusions after accidents, surgery or complications during childbirth, but their transfusions were not screened for H.I.V. or hepatitis C.
Many others were patients with hemophilia, a genetic condition that prevents blood from clotting properly. At the time, many of them were provided with a treatment derived from blood plasma called Factor VIII that provided the missing protein that hemophiliacs need for their blood to clot.
The treatment was made using pools of plasma from thousands of donors, meaning that even a small number of tainted donations could contaminate an entire pool. (Later, synthetic clotting factor proteins were developed.)
The N.H.S. imported some of the Factor VIII from the United States, where many donations were from prisoners or drug users who had been paid to donate blood — elevating the risk of contamination with H.I.V. or hepatitis C.
Campaigners who pushed for the inquiry say that British authorities did not heed warning signs about the lack of screening and about the risks associated with the use of U.S.-imported blood products.
The inquiry panel — composed of legal professionals, investigators and civil servants — heard from people who were infected, their relatives and loved ones; medical and ethics experts; government officials and politicians.
Previous inquiries and compensation offers had been deemed insufficient by victims and their families. In 2009, an independent report concluded that the tragedy could have been prevented if imports of blood from the United States had been halted, but it stopped short of blaming individual doctors or companies, and no one from the Department of Health was called to testify.
In 2015, an inquiry in Scotland prompted an apology from David Cameron, the prime minister at the time, but it was deemed unsatisfactory by victims and their families because it was unable to call witnesses outside of Scotland.
Other nations, including the United States and Japan, have faced similar scandals. In France, several senior health officials were convicted in 1992 on charges of distributing tainted blood, and France’s health minister at the time was convicted in 1999 of negligence. But he received no punishment, and two other top officials, including Laurent Fabius, the prime minister at the time, were acquitted.
