A damning report into the decades-long infected blood scandal has concluded that GPs can play a key part in ‘finding the undiagnosed’.
The Infected Blood Inquiry published its report yesterday with a ‘principal’ recommendation for the Government to immediately set up a compensation scheme for victims.
Thousands of patients have died or ‘suffered miserably’ as a result of being treated with infected blood or blood products from the NHS, particularly in the years between 1970 and 1998.
According to the report, around 26,800 people were infected with Hepatitis C after a blood transfusion and around 1,250 people, including 380 children, were infected with HIV after being treated for bleeding disorders.
The most accurate estimate is that this led to more than 3,000 deaths, and the report puts the scandal down to a ‘catalogue of failures’.
As well as the ‘serious’ failures which led to infections, the report also finds that further failures – of health professionals to keep patients well informed and of the Government to properly acknowledge wrongdoing – have ‘compounded’ suffering for the victims.
Sir Brian Langstaff, a former High Court judge and the inquiry’s chair, has made 12 recommendations for the Government, the NHS and others based on his conclusions.
In order to help find undiagnosed patients, he recommends that GP practices ask any new patients at registration whether they had a transfusion before 1996.
This should be done ‘as a matter of routine’, and those patients who fall into that category should be ‘offered the opportunity of a precautionary blood test’ for Hepatitis C.
The report said: ‘There need be no alarm for the patient about this: rather, the offer should instil confidence that their safety is being protected by the doctor, and a substantial majority of previously untested patients may expect the reassurance of a negative test.
‘However, if the test is positive (as it is likely it will be in some cases) then treatment with direct acting antivirals may follow.’
This will raise ‘awareness’ about Hepatitis C within general practice and ‘reduce the number of people diagnosed very late’, Sir Brian added.
The report also urged the medical profession to embed learnings from the inquiry, and called on the GMC and NHS England to take steps to ensure that lessons relating to clinical practice are ‘incorporated in every doctor’s training’.
This training should include excerpts from the oral and written testimony of victims to ‘underpin what can happen in healthcare’ and ‘what must be avoided in future’, the report argued.
To help build a culture of safety and increase transparency, Sir Brian also recommended that the NHS improves patient access to medical records.
He said: ‘Before the end of 2027 there should be a formal audit, publicly reported, of the extent of success of digitisation of patient records in each of the four health jurisdictions of the UK, measuring at least the levels of patient access to their personal records, their ability to identify and correct apparent errors in them, their interoperability, and the confidence of health professionals in the detail, accuracy and timeliness of any record they enter, and that little material which should be recorded has been omitted.’
Sir Brian concluded that failure in record keeping had led to patient harm or compounded suffering for those infected, and he said patients should be able to access their records ‘with ease’.
When presenting the report to the Government, he said it will be ‘astonishing’ to anyone who reads the report ‘that these events could have happened in the UK’.
‘A level of suffering which is difficult to comprehend, still less understand, has been caused, and this harm has been compounded by the reaction of successive governments, NHS bodies, other public bodies, the medical profession and others as described in the Report,’ Sir Brian wrote.
Infected Blood Inquiry recommendations
- The Government should set up a compensation scheme for those affected now
- Recognising and remembering what happened to people by setting up a permanent memorial in the UK
- Embedding learning from the inquiry in doctor’s training
- Preventing future harm to patients by achieving a safety culture
- Review duty of candour in healthcare
- Avoid a culture of defensiveness and lack of openness
- Review systems of external regulation in healthcare
- Improve access to patient records
- Ending a defensive culture in the Civil Service and Government
- Monitoring liver damage for people who were infected with Hepatitis C
- Improve patient safety with blood transfusions
- Finding the undiagnosed via GP practices
- Protecting the safety of haemophilia care
- Giving patients a voice
- Ensure clinical audits include measures of patient satisfaction or concern
- Responding better to calls for a public inquiry
- Giving effect to the recommendations of this inquiry
- Within 12 months, the Government should consider or either commit to implementing them, or give sufficient reason why they will not
Source: Infected Blood Inquiry
Prime Minister Rishi Sunak said yesterday that the publication of the report was a ‘day of shame for the British state’ and committed to paying ‘comprehensive compensation’ to victims.
In response to the inquiry, BMA chair of council Professor Philip Banfield said it was a ‘day of shame for the NHS’, but he welcomed the ‘much overdue transparency’.
He said: ‘Simply put, this should never have happened, but when it did, those involved should have been unequivocally candid in their response.
‘Today is a far too long-overdue day of vindication for the survivors and bereaved loved ones, and there must be no delay in ensuring that they are all properly compensated, as recommended in the report.’
Professor Banfield said the union will now consider the report in detail and ‘reflect on the implications for the medical profession and the doctor-patient relationship’.
‘Ultimately, all parties must take into account the recommendations to ensure nothing as tragic can happen in our health service ever again, at a point when we are still facing the same poor practice and secrecy when concerns are raised about patient safety,’ he added.
GMC chief executive Charlie Massey said the suffering endured by patients and their families is ‘unimaginable’ and that the regulator will now ‘reflect’ on the report and how to take forward its recommendations.
‘We must learn the lessons this Inquiry has set out and take the opportunity to ensure the profession and future generations of doctors know about and learn from this tragedy so that history is not repeated.’
Broke GPs to the rescue…again!!
G.P.s ideally placed————
what contracted services are we stopping to do this unfunded work? No clue what happens in general practice …
Should be done as a national screening initiative with direct access to hospital based testing.
Yet again some ignorant authorities display total lack of understanding of how the NHS, hospitals. and GPs work. They should be fired for incompetence and arrogance.
GPs cannot just ask patients if they had a transfussion before 1996 – that would cause unecessary anxiety, and patient don’t know if they had a transfussion or when it was!
GPs do not give patients transfusions, so we don’t keep records of them, and don’t know.
Who keeps records of blood transfusions? – HOSPITALS and BLOOD BANKS .
Ask them ! Then contact the patients through the whole of GP family practitioner database (which NHS ‘owns’, not GPs), and you will be able to contact them readily – or prove that your maintenance of the records was substandard and that you have been accusing GPs of growing ghosts incorrectly and maliciously for years!
This is not a GP problem, and for once it is clearly somebody other than GPs who is ‘best placed’ because THEY keep the records of what THEY do, GPs do not.
“do you remeber having any blood transfusions more than 30 years ago?”. Oh and of course our records so likely to hold the information. What planet are these deluded people on?
This is a national scandal not a local one. Public Health is ideally placed to look in to this!
Shocking why GPs? We do not and are not involved in transfusion. No record of their transfusion. The person writing the report is clueless about what GP can do but it seems the culture is to get the GP to solve problems created by others. No thanks!
Oh marvellous. I had the first enquiry yesterday… So, anyone who was in hospital during the 3 decades since 1970 who might have had any blood products will be on the phone “just in case”, cos you know, you can’t be careful enough. NHS GPs, other peoples messes sorted out by appointment of just about anyone you can name these days…
QUOTE: “I recommend:
8. Finding the undiagnosed
(a) When doctors become aware that a patient has had a blood transfusion prior
to 1996, that patient should be offered a blood test for Hepatitis C.
(b) As a matter of routine, new patients registering at a practice should be asked
if they have had such a transfusion”.
FFS…
This is a national NHS scandal. There is a Public Health service – they are ideally placed to manage this!
It is not my problem to dig them out of
Probably best if we pay the compensation as well. Case finding is not our job, presumably records of Blood transfusion are kept.