Children were used as “objects for research” while the risks of contracting hepatitis and HIV were ignored at a specialist school where boys were treated for haemophilia, the final report of the Infected Blood Inquiry has found.
Of the pupils that attended the Lord Mayor Treloar College in the 1970s and 1980s, “very few escaped being infected” and of the 122 pupils with haemophilia that attended the school between 1970 and 1987, only 30 are still alive.
Prime Minister Rishi Sunak called the exploitation of children at Treloar’s a source of “eternal shame” that is “hard to even comprehend” in a statement to the House of Commons on Monday.
Several pupils at the boarding school in Hampshire were given treatment for haemophilia at an on-site NHS centre while receiving their education.
But it was later found that many pupils with the condition had been treated with plasma blood products which were infected with hepatitis and HIV.
Haemophilia is an inherited disorder where the blood does not clot properly.
Most people with the condition have a shortage of the protein that enables human blood to clot, known as Factor VIII.
In the 1970s, a new treatment was developed – factor concentrate – to replace the missing clotting agent, which was made from donated human blood plasma.
The 2,527-page report, written by inquiry chairman Sir Brian Langstaff, concluded that children at Treloar’s were treated with multiple commercial concentrates that were known to carry higher risks of infection and that staff favoured the “advancement of research” above the best interests of the children.
The report found that from 1977, medical research was carried out at Treloar’s “to an extent which appears unparalleled elsewhere” and that children were treated unnecessarily with concentrates, particularly commercial ones rather than alternative safer treatments.
Sir Brian said: “The pupils were often regarded as objects for research, rather than first and foremost as children whose treatment should be firmly focused on their individual best interests alone. This was unethical and wrong.”
His report found there is “no doubt” that the healthcare professionals at Treloar’s were aware of the risks of virus transmission through blood and blood products.
He wrote: “Not only was it a prerequisite for research, a fundamental aspect of Treloar’s, but knowledge of the risks is displayed in what the clinicians there wrote at the time.
“Practice at Treloar’s shows that the clinical staff were well aware that their heavy use of commercial concentrate risked causing Aids,” he continued.
Despite knowledge of the dangers, clinicians proceeded with higher-risk treatments in attempts to further their research, the report concluded.
Sir Brian wrote: “It is difficult to avoid a conclusion that the advancement of research was favoured above the immediate best interest of the patient.”
He continued: “In conclusion, the likeliest reason for the Treloar’s treatments having the catastrophic results they did is that clinicians were seduced by wishing to believe, against available information, that intensive therapy might produce better overall results; by the desirability of convenience in administration rather than the safety of treatment and by ignoring some of the treatment implications of the research projects they wished to pursue.”
The Lord Mayor Treloar College, which has since been rebranded as Treloar’s, was established in 1908 as a school which gave disabled children a better chance to receive an education alongside any medical treatment they might need.
It was originally a boys’ school but then merged with a girls’ school in 1978 to become co-educational.
From 1956, boys with haemophilia began attending the school. After it was discovered pupils had been given infected blood plasma, the NHS clinic at the school closed.
The report also highlighted that parents and children at Treloar’s were given little information about their care and the related risks, and that parental consent was not sought regarding the use of different treatments.
Sir Brian wrote: “The evidence before the inquiry suggests, overwhelmingly, that there was no general system or process for telling parents of the risks of viral infection.
“Nor were pupils told.
“Parents were not given details, nor even core information, about their children at Treloar’s for haemophilia.
“They were not told, for instance, that despite their home clinician’s recommendations as to the treatment product, the pupils were being given a range of different concentrates.”
In many cases, the report states, research was conducted on patients, including children, without consent or consent of their parents and without informing them of the risks.
“They gave a consistent account that there had been no meaningful consultation with their parents, or with them,” Sir Brian continued.
In a statement on Monday, Rishi Sunak issued a “wholehearted and unequivocal” apology to the victims of the biggest treatment disaster in the NHS, vowing that “comprehensive” compensation will be delivered “whatever it costs”.
Referencing the harm caused to children at Treloar’s Mr Sunak said: “Sir Brian finds an attitude of denial towards the risks of treatment.
“Worse, to our eternal shame in a way that is hard to even comprehend, they allowed victims to become objects for research
“Many including children at Lord Mayor’s Treloar College were part of trials conducted without their or their parents’ knowledge or consent.”
Sir Brian said it was “unconscionable” that children at the Treloar’s school were treated in a way that “trumped safety” without the risks being explained to their parents, at an event in London on Monday marking the report’s release.
He told the audience at Central Hall in Westminster: “The pupils were often regarded as objects for research rather than first and foremost as children whose treatment should be firmly focused on their individual best interests alone.
The chair of the probe continued: “It was unconscionable to treat children with concentrates capable of transmitting serious viruses without explaining those risks clearly to their parents.
“There were multiple research projects where informed consent for participation was neither sought nor given. This was unethical and wrong.”
Treloar School and College said in a statement: “The inquiry’s report shows the full extent of this horrifying national scandal. We are devastated that some of our former pupils were so tragically affected and hope that the findings provide some solace for them and their families.
“The report lays bare the systemic failure at the heart of the scandal.
“Whilst today is about understanding how and why people were given infected blood products in the 1970s and 1980s, it is absolutely right that the Government has committed to establishing a proper compensation scheme. This must happen urgently after such a long wait.
“On a recent visit to the school and college, our former students highlighted the need for a more public and accessible memorial to ensure the lives of all those impacted are remembered. This is a key recommendation of the report and something which we are absolutely committed to exploring with them.
“We’ll now be taking the time to reflect on the report’s wider recommendations.”
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