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Three questions that will determine the Infected Blood Inquiry’s success

The Infected Blood Inquiry should be a catalyst for confronting other injustices.

Someone holding up the final report of the Infected Bloody Inquiry.
So many long-running inquiries have failed to produce the change people need – partly because once an inquiry reports, there is almost nothing in place to hold government to account.

Emma Norris says the Infected Blood Inquiry’s recommendations should be implemented in full – and calls for a new approach for ensuring the government is held to account if it fails to do so

The final report of the Infected Blood Inquiry, published on Monday, is damning in its conclusions and, after decades fighting for justice, is vindication for the victims and their families. 

Sir Brian Langstaff’s conclusions were stark: people were repeatedly and wrongly told that they were given the best treatment available at the time, while state institutions sought to avoid admitting wrongdoing, ducked compensation and repeatedly refused calls for an independent inquiry. 

The prime minister has apologised. The leader of the opposition has apologised. The chief executive of NHS England has apologised. The tone in Parliament was one of genuine reflection and contrition. But we have been here before. In the wake of other major public inquiries there has been contrition and commitments to learn lessons from those with power – but change itself has been much rarer. For this inquiry to be any different, three key questions need asking: 

1. Will the government implement the recommendations of the Infected Blood Inquiry? 

Compensation arrangements for victims and their families must be implemented without delay. The prime minister has pledged that ‘whatever it costs to deliver this scheme, we will pay it.’ John Glen, the Cabinet Office minister, has announced interim payments of £210,000 within 90 days – ahead of the full compensation scheme. This is not just about the amount of money required – close to £10bn – but the timeliness with which families are compensated. They have already waited decades. The approaching general election, and its aftermath, must not distract from the design and delivery of the full compensation scheme. 

Sir Brian Langstaff also made recommendations to break through the culture that enabled denial and obfuscation for so long. This includes the call for a statutory duty of candour for civil servants – a legal duty to speak out in instances like this and changes to clinical training. Culture change has proved endlessly difficult to achieve – particularly on scandals relating to patient safety. But measures that strengthens the resolve of public servants and clinicians to speak should again be implemented without delay.

2. Will anyone hold government to account for implementing the recommendations?

So many long-running inquiries have failed to produce the change people need – partly because once an inquiry reports, there is almost nothing in place to hold government to account.  

Past inquiries, including the high-profile Mid Staffs inquiry, have put forward similar recommendations on culture, candour and patient safety. These have not, however, resulted in change.  

A failure to implement recommendations only compounds the harm to victims and their families, and the delay and inaction that have characterised successive governments’ approaches to the infected blood scandal can be felt throughout the report. Sir Brian argues that parliament should hold government to account for implementing his recommendations – via the Public Administration and Constitutional Affairs Committee and that this role should become permanent. We have made similar arguments in our own work. Improving post-inquiry accountability – or rather, establishing any accountability procedures at all – would be an important step forward. 

3. Can the state act to avoid repetitions of similar tragedies in the future – including those that are unfolding right now?

Public inquiries are crucially important. They take time, cost money and give people hope that they will provide justice and accountability. At their best, as we have seen this week, they give overdue recognition to families who have fought long and hard. But public inquiries are too often launched because the state has failed to act in time.  

The wrongs of the infected blood scandal had been known for decades by those involved, but people often recognise system failure long before action is taken.

This week the former Post Office CEO Paula Vennells will be questioned about what she knew of postmasters being wrongly convicted of theft – a miscarriage of justice that has been going on for over 20 years. A report into the unnecessary suffering and death caused by systematic failures in maternity services – the fourth inquiry into maternity services in the last decade – has recently been published. In all these cases, pain could be alleviated if there was much stronger resolve to grip these problems earlier – and bring about the changes to stop them happening again.  

Government can now do the right thing – at last – for the victims and families in the infected blood scandal. Apologising sincerely and promising to implement compensation was the first step. It is also the easy one. Finding the resolve and mechanisms to confront the problems we know exist is much harder.

The final report of the Infected Blood Inquiry should be implemented in full – but this moment should also be a catalyst for confronting other injustices happening right now and acting before they end in similar inquiries.  

Institute for Government

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