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Justice Delayed …. – politicalbetting.com
Justice Delayed …. – politicalbetting.com
"People put their trust in doctors and the government to keep them safe. And that trust was betrayed."Infected Blood Inquiry chairman Sir Brian Langstaff says the government "compounded the agony" of those affected by the scandal. pic.twitter.com/yPg0zxGN28
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...Langstaff ended his statement by referring to Perry Evans, who had haemophilia, and was infected with HIV in the 1980s, and he gave evidence to the inquiry on the first day it opened. He had been able to lead an active life. But he died five weeks ago, Langstaff said.
...Langstaff said he wanted to ensure his recommendations were implemented.
He said that, in his letter to John Glen, the Cabinet Office minister handling the inquiry, he said that he was not yet able to say the inquiry had fulfilled its term of reference in terms of the “nature, adequacy and timeliness” of its conclusion
The reference to “timeliness” provoked a round of applause.
I don't hear any real plan from anybody on what to do. And unlike the US, we can't just turn the money print to max, as we found with Liz Truss, if you have radically uncosted ideas, the market won't accept it.
We do seem to have a deep seated problem in this country of institutional accountability. Starmer could do worse than to take aim at this in the Labour manifesto, and promise more safeguards, faster justice and more accountability of leaders.
Most recently, Howard Davies comes to mind, everywhere he has been, there has been a scandal that he is closely linked to. But then he pops up again a few years later in a similar position of power at a different organisation as if nothing happened.
Also interestingly politically polarized, the Telegraph reports it avidly and the Guardian airbrushes it.
British exceptionalism is often wrong; either when we see ourselves as uniquely better than others, or worse.
Having said that, both France and Germany had similar tainted blood scandals, and both were settled decades ago - in the German case, with prosecutions. I do wonder if the involvement of the NHS - apparently a national treasure - has been a factor in this hideous delay.
I was taught at medical school in the Eighties about the dangers of pooled blood products (including factor VIII).
We weren't taught about the cover up though, that took place at a much higher level in the DOH and Blood Transfusion Service, a very different level to the front line chaos in maternity services up and down the land.
I think the maternity scandals come back to the often very poor relationships between medical staff and midwives, and that has been a problematic issue since the NCT and Wendy Savage etc.
1. Why are people so defensive in this sort of situation?
2. What can we do to encourage a problem-solving, as opposed to face-saving reaction to problems being identified?
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And the passage of time probably precedes criminal consequences for some of the perpetrators.
https://www.theguardian.com/uk-news/article/2024/may/20/politicians-should-hang-their-heads-in-shame-over-uk-infected-blood-scandal
The inquiry chair, Brian Langstaff, concluded in the report, published on Monday, that the infected blood scandal was avoidable and worsened by a government cover-up.
Clive Smith, the chair of the Haemophilia Society, said: “To our community that’s no surprise. We’ve known that for decades. Now the country knows, and the world as well.
..Citing the recent example of the Post Office Horizon IT scandal, as well as maternity scandals in hospitals, Smith said such scandals continued to happen in the UK because the recommendations of public inquiries were ignored. ”That must stop today,” he said.
The government’s plan to provide a detailed response on Tuesday suggested it was “engineering a political moment which many people will find offensive and will continue to compound suffering”.
Although it is not covered by the scope of the report, many victims want to see criminal charges brought against those involved in the scandal. As a criminal barrister, Smith thought this would be difficult.
“If there were to be charges of substance against people, the time sadly has gone for that, because doctors for example who were testing their patients for HIV and not telling them, who went on to infect their partners, they could and should have been prosecuted for gross negligence manslaughter,” he said.
But criminal prosecutions could also be levelled at those who covered up and removed medical records as this could represent the “systematic destruction of documents”, he added.
“I don’t think it’s too late, but I think the evidence needs to be reviewed and considered and if there is evidence then people do need to be prosecuted because sadly this report is landing today and I doubt there are many, if any, people at home thinking ‘I’m going to get a knock on the door from the police.’
“I’m afraid until people are actually concerned their actions will have consequences, we will not see the sort of institutional change Sir Brian has recommended today.”..
On topic: thanks for the (as usual) good article, Cyclefree.
"There is the indifference which can be one of the causes of a problem. But what is often worse is the indifference shown to victims after problems have arisen. It is hard to understand the callousness of some decisions. Perhaps it is made easier by forgetting or ignoring those who are affected. And, of course, there are often legal and other reasons for doing what can seem cold or cruel.
What should happen?
After something goes badly wrong, there is one question which should be asked by those on whose watch this happened: what is the goal? If it is to protect the institution at all costs (what is usually done), all can be justified. But if it is to solve the problem (what should be done but often isn’t) — to learn important lessons, provide some element of restitution to those suffering harm — then forgetting or minimising the human element is disastrous.
People who have suffered want two things above all: to be heard and justice — not simply justice for the perpetrators — but the acknowledgement of the truth of what happened and why. Ignoring this makes them more determined not less. Take the Aberfan parents: they wanted it recorded that their children had been killed by the National Coal Board. They did not get this, despite the findings of the official inquiry. By contrast, the Hillsborough families fought for years to get a verdict of unlawful killing. It mattered that what happened was not simply written off as an accident, but a consequence of actions and decisions by human beings which could and should have been different. And which would be different in future if the truth was understood and acted on.
It feels like indifference to those on the receiving end. But perhaps its impulse is less the effect on the victims but more a desire to save face by those responsible. The truth about what happened was important to the families. It mattered that this was publicly acknowledged. But this public acknowledgement is something the authorities find hard to accept or admit. (The paradox is that the later it is said the more victims will want something else — compensation or prosecutions — as a substitute.) It is not just concerns about having to pay compensation which drives this, important as it is. It harms an institution’s self-image and, often, of senior people within it. “We got it wrong.” is hard to say. If “we get it wrong” what sort of a “we” are we, really? Avoiding the shame of having to admit that your actions or inactions have been responsible for the suffering of others is what drives this defensiveness and indifference."
And too many of the gatekeepers fail to get this too. Lawyers included. See, once again, the Post Office.
https://www.theguardian.com/uk-news/article/2024/may/20/read-the-infected-blood-inquiry-report-in-full
I think one factor is that any public-facing organisation will receive a lot of criticism, some more warranted than others. It can become habitual to bat away criticism without examining whether it is justified before doing so.
#NU10K
Labour leads by 22%.
10th consecutive week with a Labour lead of 20% or more.
Westminster Voting Intention (19 May):
Labour 45% (+3)
Conservative 23% (+2)
Reform UK 12% (-3)
Lib Dem 10% (-2)
Green 5% (-1)
SNP 2% (-1)
Other 1% (–)
Changes +/- 12 May
"Post Office lawyer who oversaw Alan Bates case refusing to co-operate with inquiry
It is understood that Jane MacLeod is living in New Zealand and the inquiry cannot compel her to give evidence while she is abroad"
https://www.telegraph.co.uk/news/2024/05/17/post-office-lawyer-who-oversaw-bates-case-wont-co-operate/
I wonder whether this will be, mile for mile, the most expensive ship journey ever?
The stupid hero worship of the NHS, for instance, has not helped.
The true master of a domain will be happy to explain in simple English, to an outsider.
Obfuscation and obscure terminology are for the mediocre.
*in todays' money
'By insisting on waiting for the inquiry to conclude before making a final decision on redress, Rishi Sunak had "perpetuated the injustice", Sir Brian said.'
https://www.bbc.co.uk/news/live/uk-69025640
Is it likely that he'll be announcing a compensation scheme in today's statement in the HoC?
https://www.gutenberg.org/files/1213/1213-h/1213-h.htm
Called "Qualified Immunity." Not a subject I know in a lot of detail, and I suggest that certain practices here - such as officers avoiding responsibility by retiring, are on the same spectrum. IIRC we have had at least *some* reform of that.
In the UK I've seen a number of very strange outcomes of offences which feel fishy at the least. Because of my interests I see these occasionally in cases around motoring law.
The doctrine of qualified immunity allows state and local officials to avoid personal consequences related to their professional interactions unless they violate “clearly established law” and has been repeatedly used by police officers to escape accountability and civil liability for engaging in violent and abusive acts against the public. In practice, this often means that, unless there’s a case with nearly identical facts on the record, these officials can violate a person’s rights without being held personally responsible for their actions.
https://www.naacpldf.org/qualified-immunity/
Events transpiring not necessarily to the advantage of Sunak's wait and see policy, on this and on election dates
Starmer leads Sunak by 14%.
At this moment, which of the following do Britons think would be the better Prime Minister for the UK? (19 May)
Keir Starmer 44% (+4)
Rishi Sunak 30% (+2)
Changes +/- 12 May
It's not mentioned in the report's five page summary of the causes of so many being unnecessarily infected by blood products, and the failure to address that.
Though you could of course infer it.
From the summary at the head of the report:
The chapters that follow make clear who is responsible for each of these failings, though in general I can say that responsibility for much lies with successive governments, even though others may share some of it.
...I have no doubt however that, despite the difficulties of time and scale, the conclusion that wrongs were done on individual, collective and systemic levels is fully justified by the pages that follow; that a level of suffering which it is difficult to comprehend, still less understand, has been caused to so many, and that this harm has, for those who survived long enough to face it and for those who, infected and affected, are now able to read this, been compounded by the reaction of the government, NHS bodies, other public bodies, the medical professions and others as described in the Report.
SUNAK: This is a moment of shame for the British state.
@henrymance
He's going to have to be more specific
Starmer vs Sunak (19 May):
Starmer leads Sunak by a fair margin on ALL 17 leadership characteristics polled, including:
Represents change (48% | 23%)
Can work well with foreign leaders (44% | 31%)
Cares about people like me (45% | 23%)
Can build a strong economy (43% | 31%)
Post Office scandal (very little compensation yet paid)
Windrush scandal (much compensation still to pay)
Blood scandal (no compensation paid)
There's a pattern Sunak.
Feyenoord boss Arne Slot has been confirmed as Liverpool's new manager.
Thanks @Cyclefree for a nice summary of institutional failure.
These are the events of five decades, and involve both government and large parts of the NHS. And the report seems to describe failings throughout that entire time.
What was going on in the minds of the executives at these companies? In the Panalba Role-Playing Case Study, developed at the University of Pennsylvania and based on the real case of the drug Panalba, groups are asked to role-play as executives in a pharmaceutical company, one of whose star drugs has been found to be causing deaths. They are given a range of options, from recalling the drug to continuing to produce and market it until it’s banned. Almost every group that has ever participated has decided to keep selling. The roles they play override the participants’ personal morality, even though – unlike real-life executives – they aren’t in line for any financial rewards.
https://www.lrb.co.uk/the-paper/v45/n22/florence-sutcliffe-braithwaite/we-ve-messed-up-boys
The first is the failure to make patient safety the paramount focus of decision-making and of action – whether it be decisions by individual clinicians, haemophilia centres or hospitals, or decisions taken at a regional level by transfusion centres, or decisions taken at a national level by governments.
The second theme is the slow and protracted nature of much of the decision-making examined in this Report: by way of example, the length of time taken for haemophilia centres to adapt treatment policies and practices, or the length of time taken by clinicians and NHS organisations to recognise the need for better transfusion practice, or the delays with regard to AIDS donor leaflets, or the delayed decision-making by government regarding the introduction of Hepatitis C screening of blood donations and the delay in deciding to undertake a lookback.
The third is the profoundly unethical lack of respect for individual patient autonomy, which will be most starkly apparent to readers from the chapters on People’s Experiences and Treloar’s and from parts of the chapters on Haemophilia Centres: Policies and Practice and Blood Transfusion: Clinical Practice.
The fourth theme, closely related to the third, speaks of the dangers of clinical freedom. Clinical freedom is the idea that doctors should be free to do what they believe to be right for an individual patient. But the danger of clinical freedom in the context of infected blood and blood products is that it allowed doctors to follow unsafe treatment policies and practices (such as administering commercial factor concentrates to young children, or giving unnecessary transfusions to postpartum women), and it meant that others (in particular the health departments and Chief Medical Officers) held back from providing advice, guidance or information in the misguided belief that this would interfere with clinical freedom.
The fifth theme is that of institutional defensiveness, from the NHS and in particular from government, compounded by groupthink amongst civil servants and ministers, and a lack of transparency and candour. These factors drove the response of government over the decades.
The institutional defensiveness identified above is damaging to the public interest. But the sixth principal theme that emerges from this Report is the damage that was done by that defensiveness and the accompanying lack of transparency and candour to the very people whose lives had been destroyed by infection. The harms already done to them were compounded by the refusal to accept responsibility and offer accountability, the refusal to give the answers that people fervently sought, the refusal to provide compensation, leaving people struggling and in desperate circumstances, the thoughtless repetition of unjustified and misleading lines to take, and the lack of any real recognition and of any meaningful apology...
For example it was deliberately *under insured* - that is, White Star carried a big chunk of liability themselves. This was in reaction to the scandals involving over insuring ships that then conveniently* sinking them.
*somewhat inconvenient to the crew and passengers of said ships. But very few complaints registered after the fact. So there’s that.
..In Germany, from 1965 onwards, all blood donated for possible transfusion was tested to see if it contained abnormally high levels of a liver enzyme, alanine transaminase (“ALT”). This increased the protection..
..The UK never adopted ALT screening...
...It began to be apparent as soon as 1972 that despite the introduction of testing for Hepatitis B there was still a significant risk of post-transfusion hepatitis. It was increasingly reported that hepatitis was occurring after transfusion, yet when tested the patient was suffering neither from Hepatitis A nor Hepatitis B. Of particular note was the report by Dr Alfred Prince and others in The Lancet in August 1974 that an agent other than Hepatitis B (which became known as non-A non-B Hepatitis (“NANBH”)) was the cause of 71% of cases of post-transfusion hepatitis; this article warned of the possibility that “non-B hepatitis may play a role in the aetiology of some forms of chronic liver disease.” The Lancet was one of the most widely-read journals by clinicians in the UK: no clinician dealing with transfusions had any reason to be unaware of this conclusion.
..And by September 1980 Dr Diana Walford of the DHSS was confident enough to write a memo saying: “I must emphasise that 90% of all post-transfusion (and blood-product infusion) hepatitis in the USA and elsewhere is caused by non-A non-B hepatitis viruses which (unlike hepatitis
By the very start of the 1980s, therefore, it was clear that hepatitis caused by a blood transfusion, or treatment with a blood product, carried with it a serious risk of long-term consequences, and it was known that this could not be linked simply to Hepatitis B infection...
Their stories of death traps owned by other companies were illuminating.
They loved LNG - because the consequences of LNG are in the kilotons, the ships were properly maintained and crewed.
And when you announced on the radio at a strait or similar choke point that you were an LNG ship, the way the usual dozy watch officers would get their ships out of the way… apparently watching a beautiful, wide, clear channel opening up on the radar screen was a sight…
See also the earlier discussion of pilots being able to be put under sufficient pressure to ignore all of their training about severe weather, in order to attempt to operate their charter or VIP flight - often at the cost of their own lives.
Why do we, as a country, find it so hard to say “sorry “ ? Why do people not accept responsibility for their actions? And why oh why do we never hold those so failing to account, if only to make fessing up and sorting a rational response?
Sigh.
Any lawyer involved who was instructed five years ago, will have understood the bare bones of what happened and why four years and 50 weeks ago. The rest is theatrics.
https://x.com/frances_coppola/status/1790353069907075416?s=61
Yet another establishment failure though.
We are far too focused on making sure that we haven’t missed anything instead of focusing on the main point.
We are utterly useless at pricing the consequences of delay.
https://x.com/bbcnews/status/1792429534916030962?s=61
Having said that, an apology for an institution's failures is still valuable.
This, in response to the then developing understanding of AIDS:
..In 1982 the DHSS published a report making recommendations as to the role of RTCs in promoting good practice in blood transfusion, including “economies in blood usage”. A circular issued by the DHSS in 1983 recommended regular meetings between RTCs and hospital consultants to consider such matters. Similar recommendations were produced by SNBTS. In practice the extent to which individual RTDs played a role in educating clinical colleagues on the use of blood varied from centre to centre and over time. One of the obvious steps that treating clinicians could (and should) have taken once it was understood that HIV was a blood-borne infection, was to reduce all patients’ exposure to blood and blood products as far as reasonably practicable. However, RTDs did not, on the whole, consider that they had a role in trying to influence treating clinicians to prescribe one product over another on the grounds of safety. The principal reason for this was respect for the clinical freedom of doctors.
All RTC directors (for England, Wales and Northern Ireland) who were in post in the years 1982-1984 before blood products were heat treated against HIV gave evidence that if they had been asked to increase their production of cryoprecipitate (a much lower-risk product) during the mid 1980s, they would have been able to do so, and quickly. They were all clear that no such request was made of them by treating clinicians and so no steps were taken to achieve this. In Scotland Professor Cash emphasised the role of cryoprecipitate and raised concerns about the purchase of commercial products and Dr Brian McClelland produced a paper which suggested reassessing the role of single-donor or small pool cryoprecipitate. However the extent to which these actions influenced the prescribing practices of haemophilia clinicians in Scotland is doubtful...
The year he retired, his family took him on a canal boat trip. He promptly ran the narrowboat aground and got it stuck.
(He's a grand old chap, and still going strong. He lives a short walk from the sea to this day.)
Thanks Labour.
One LNG captain told me of the time a docking went slightly wrong. Fortunately the hull worked as designed. As a crumple zone. It ended up inches away from the cryotank - fortunately the engineers had avoid the ramming effect - collapsing structure pushes a beam through the next watertight compartment.
Ditto with the PO - the PO was told in 2001 of the problems which were set out in a judgment in 2019. The Chair was told in a letter in 2003. Over a decade was wasted denying the problems, let alone putting them right and instead making them very much worse. So there is more to find out: not just about the problems but the responses and the cover up.
Crises never start out as big problems. But as small ones which are ignored.
The race to the bottom continues.
Wittgenstein in one of his more lucid moments.
..An internal DHSS meeting to consider AIDS took place on 3 June 1983, at which there was no discussion whatsoever of Dr Galbraith’s letter and paper, nor any discussion about any different approaches to the treatment of bleeding disorders. This reflected the departmental position that, having regard to the principle of clinical freedom, it was not the role of the DHSS to provide guidance or advice to clinicians. This was a short-sighted position for the DHSS to adopt and ultimately a dereliction of its responsibility to patients...
..In June 1983, the Council of Europe’s Committee of Ministers published a resolution which was addressed to the governments of member states. Its overarching recommendation was “to take all necessary steps and measures with respect to” AIDS. The first detailed recommendation was “to avoid wherever possible the use of coagulation factor products prepared from large plasma pools; this is especially important for those countries where self- sufficiency in the production of such products has not yet been achieved*”. The government took no steps in response to this recommendation.
The second recommendation was to tell clinicians and patients about the risks of treatment with blood and blood products and the possibilities of minimising the risks. The UK government took no steps in response to this recommendation. Dr Walford’s explanation was that this would not be a usual course of action for the DHSS...
*Which then described the UK.