Senior civil servants should be subjected to new statutory duties of accountability for the "candour and completeness" of advice given to ministers and departmental top brass, according to the final report from the Infected Blood Inquiry.
Tightened rules designed to prevent officials and ministers peddling misleading or simply inaccurate responses to concerns are among a raft of recommendations in Sir Brian Langstaff's report.
The infected-blood scandal has claimed more than 3,000 lives through the use of contaminated transfusions and contaminated blood products since the 1970s – leaving patients exposed to HIV and hepatitis C. Tens of thousands of people have been infected.
In his 2,500-plus page report yesterday, Langstaff said the scandal was the result of a "catalogue of failures" that amounted to a "calamity" that could – and should – have largely been avoided.
In addition to medical failings, the report highlights repeated use of wrong, misleading and defensive government responses, and the destruction of documents in a "deliberate attempt to make the truth more difficult to reveal".
Langstaff said departmental officials' responses had seen civil servants and ministers adopting "lines to take" without enough thought, and when those lines were "inaccurate", "partial", in need of qualification. In some cases, government responses ignored findings made by courts.
The report said that in relation to hepatitis C, ministers "took on faith" what civil servants told them, and that civil servants took on faith what departmental files said.
"No one stood back and reflected," it said. "No one asked questions – could this really be right? How could the best treatment available lead to the infection of so many?"
The report said the result was that for around 20 years, the line that patients had received the best treatment available "became a mantra" that was never questioned.
"The cruelty, for those infected and affected, of hearing, over and over, that they had received the best treatment available, that testing had been introduced as soon as possible, that they had been inadvertently infected, should not be underestimated," it said.
"The use of the lines contributed to delay in there being a public inquiry; it almost certainly meant that those infected and affected did not get the financial and psychological support they would otherwise have received; it contributed to a loss of trust in the health service and in the ability of government to understand and respond to genuine concerns and complaints."
The report said the scandal had underscored a corporate-memory problem in the civil service. It said it was apparent that there was "no mechanism" to ensure departments had sufficient corporate memory of the reasons why previous decisions were, or were not taken – and the facts that informed those decisions.
"Though a number of witnesses were asked, none actually knew the facts underpinning a number of 'lines to take' adopted in the 1990s," the report said. "When they slipped into what they preferred to believe, rather than taking an objective view of the past, they were supported by a degree of groupthink rather than by a true 'corporate memory'."
Langstaff's proposals to end the "defensive culture" identified in the civil service and government call on ministers to consider introducing statutory duties of candour for civil servants and ministers in their day-to-day work that would be in line with legal duties expected in evidence to courts. The move would effectively beef up non-statutory duties in the civil service code.
The report says that if ministers decide not to introduce a strengthened duty of candour across the whole civil service, senior civil servants should face new obligations.
Langstaff said that in that situation, members of the SCS should be placed under a "statutory duty of accountability" for the "candour and completeness" of advice given to permanent secretaries and ministers, and the candour and completeness of "their response to concerns raised by members of the public and staff".
The inquiry chair said the government should consider the extent to which ministers should be subject to duties beyond those currently contained in the ministerial code.
As part of his exploration of the civil service's role in the scandal, Langstaff quoted paragraphs from a 2023 CSW opinion piece by former Department of Health permanent secretary Dame Una O'Brien, which explores issues around speaking up in the workplace.
Other recommendations in the report include giving increased power to parliament's Public Administration and Constitutional Affairs Committee in relation to triggering public inquiries.
Under Langstaff's recommendations, PACAC would recommend to an appropriate minister that there be an inquiry if members believe there are sufficient concerns about an issue – or that there are likely to be lessons learned.
That minister would be required to publish detailed reasons if they disagree. Those reasons should be "sufficient to satisfy PACAC that the matter has been carefully and properly considered".
Rishi Sunak said publication of the final Infected Blood Inquiry report was " a day of shame for the British state", marking a "decades-long moral failure at the heart of our national life".
"From the National Health Service to the civil service, to ministers in successive governments at every level, the people and institutions in which we place our trust failed in the most harrowing and devastating way," the prime minister said.
"They failed the victims and their families – and they failed this country."
Sunak pledged the government would work with health services and civil society "to ensure that nothing like this can ever happen in our country again".
Cabinet Office minister John Glen is due to set out initial details of a compensation scheme for infected-blood scandal victims later today.