Infected Blood Inquiry

Read the latest news on the Public
Inquiry into Contaminated Blood

The taintedblood Timeline  -  what really happened...

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Magna Carta - 15th June, 1215

No of entries selected: 7 of 711
Warnings of Dr Dealler About Risk of BSE / CJD in Transfusion Repeatedly Ignored
People with haemophilia were failed repeatedly in 1995 and 1996 when, despite serious warnings over the risk of BSE / CJD in transfusion, Bio Products Laboratory (BPL), continued to manufacture and release human-derived plasma products which they had been told might not be safe for use by haemophiliac patients. Beginning in 1995, microbiologist Dr Stephen Dealler issued repeat warnings over a two-year period to the Scottish BTS, to BPL and even to the UK Haemophilia Society.

The following is quoted verbatim from Dr Dealler's Witness Statement to the BSE Inquiry:

"In 1995 and 1996 I was in repeated contact with Dr Gascoigne of BioProducts Ltd (BPL), who seemed to take little further action. I was in contact with the Scottish BTS (Dr Turner), who listened helpfully but hoped it would turn out that humans did not get BSE..." (see Pg. 14, para 92 of PDF below)

"I was in contact with the British Haemophilia Society in London in 1995 and told them of the risk that they may be taking (I did not go through the mathematics but these show that the level of infectivity in plasma may be adequate to transfer through the quantity used by haemophiliacs)."

"The worry has always been that, as the potential problem resulting from BSE is so great, and the possibility that blood transfusion in the UK may only be partly sustainable, it would be extremely difficult for the BTS/National Blood Authority to accept what I was telling them." (see paragraph 94)

NOTE: We are extremely disappointed to read that various bodies such as BPL and the Haemophilia Society were alerted in 1995 to the potential risk of CJD/BSE in blood products. We see little evidence of any appropriate action that might have been taken to help prevent exposure to vCJD-implicated batches of BPL & PFC factor VIII. We know that many UK haemophiliacs did not receive their first batches of vCJD-implicated Factor VIII, particularly BPL, until 1995; and this includes one of the authors of this Timeline, who did not receive his first suspect batch [FHE4437] until 21 September 1995.

Source: Link #1
Tables of vCJD-Implicated Batch Numbers:
Link #3
Type: Witness Statement to the BSE Inquiry, Dr Stephen Dealler
Location: UK
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1 November
John Sloggem: CJD and Blood Products - Basically the Risk is Theoretical !
In a briefing note by John Sloggem intended for Professor Gull for the Biologicals Subcommittee (CSM) meeting of 1st November 1995, CJD and plasma-derived blood products are discussed as follows:

J. SLOGGEM: "There is no experimental evidence in animals to suggest that CJD is transmitted by whole blood or plasma. Plasma being cell free is thought safer because scrapie infectivity is tissue associated and sheep plasma - cell free - appears clear of scrapie infectivity."

..."There is no epidemiological evidence to suggest that there is a higher incidence of CJD in groups of patients receiving plasma derived products regularly. They are closely monitored by clinicians presumably any major excess number of cases would be spotted."

J. SLOGGEM: "Basically the risk is theoretical."

..."Besides classical blood products, anything with a blood derivative could be considered "risky" and mean that vaccines, other biological and biotechnological products would be withdrawn."

"The risk/benefit ratio was not considered in favour of withdrawal on the basis of to-date theoretical risk."

Background: From these statements, it appears as if John Sloggem neither read nor absorbed Dr Pickles paper on Prions and Blood Products ('ACVSB 9/9') from February 1991 - which incidentally was over 4 years earlier. Mr Sloggem should have been able to recall from the ACVSB background paper that CJD was going to be a problem in blood products, especially since Dr Pickles (see related entries link below) recorded that viral-inactivating procedures were unlikely to be adequate to deal with the CJD agent. We would hardly call this 'theoretical'.

NOTE: It is also possible to see from the above comment on 'monitoring' exactly why people with haemophilia have very much been ignored and left ill-informed over vCJD.

Type: BSE Inquiry Evidence (Briefing Note MF81013/2 0414)
Location: UK
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6 February
NHS: No Need to Inform Patients Who Have Received vCJD-Implicated Products!
A letter was sent from Leeds NHS Executive headquarters to all NHS Trust Medical Directors and Health Authority Chief Executives dated 6 February 1998. The letter, which discussed nvCJD and patients who have received implicated blood products, stated: "...there have been a number of recall exercises over recent months" and advises doctors not to tell patients why their plasma products have been recalled.

"The advice which the Department has received from ethics experts and other advisory bodies is that there is no need to inform patients because:

  1. is thought unlikely that nvCJD will be transmitted in this way;
  2. ...there is no diagnostic test for nvCJD;
  3. ...even if a test was available, there is no preventative treatment that could be offered."

The letter went on to explain that: "In these circumstances the general view is that patients will not benefit from this knowledge, and that uncertainty created by informing patients could have the contrary effect causing unjustified worry and creating a permanent blight on their lives in relation, for example, to obtaining life of health care insurance."

BACKGROUND: This letter was undisclosed and the haemophiliac community and campaign groups knew nothing of it until Carol Grayson and her husband Pete Longstaff received some leaked letters around September 2000. Carol informed the Guardian, the Newcastle "Journal" and "Private Eye" in the year 2000 and an item on the subject later went out on the BBC's "Watchdog" programme. As a result of these media articles, UK physicians eventually wrote to their patients in 2001 asking them if they wished to be informed of their exposure to vCJD.

NOTE: How can the NHS Executive even attempt to justify not informing patients? We don't think much of their "expert ethical advice"! We feel it is quite scandalous to learn that if Carol Grayson hadn't got hold of the leaked documents we would never have learnt of just how long the NHS, DOH and even BPL had already sat silently on the information since February 1998. Also, it is clear that they certainly appeared to have had no intention of ever telling people with haemophilia & other bleeding disorders directly. Without intervention from the press there would never have been the series of vCJD look-backs.

It is clear from this behaviour that the authorities were quite happy to lie to our faces. So when, exactly, would they have informed us of our exposure?

Source: Link #1
Type: NHS Executive Letter - Appendix 1. Dated 6th February 1998
Location: UK
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15 February
First Haemophiliac Known to have Contracted vCJD from Plasma Products
On 15th February 2009, the Telegraph reported that an elderly person with haemophilia had contracted vCJD from NHS Plasma products. The man was said to have died from another cause but vCJD was discovered following a post-mortem.

In September 2004 health officials wrote to 4,000 people with bleeding disorders, warning them that they were at a "small increased risk" of variant Creutzfelt-Jakob disease, the human form of mad cow disease. Most of these people were haemophiliacs.

Following the publication on 23rd February 2009 of the report and recommendations of the Lord Archer's Independent Inquiry into the issue of contaminated blood and blood products (see 3rd link below), TaintedBlood very much hopes that, following this latest disgraceful example of Department of Health incompetence over the handling of 'at-risk' patients, the Government finally tackles this appalling scenario head on and deals with it once and for all. This is the very least that could be expected for this small, vulnerable, grievously damaged community.

NOTE: TaintedBlood would like to express particular disgust at the way in which this news was released. We understand that none of the agencies dealing with the haemophilia community, such as the Haemophilia Society, were informed of what had happened. None of the 4,000 people known to have received vCJD-implicated batches of plasma products - most of whom were haemophiliacs - were afforded the opportunity to have any help or counselling prior to this announcement. We do not, however, express any element of surprise, since we have been warning of exactly this scenario since 1995/1996.

Source: Link #1
Link #2
Type: Press Article - Telegraph
Location: UK
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17 March
House of Lord Debate - Amendment 133 - Moved by Lord Morris of Manchester
On Tuesday 17th March 2009, Amendment 133 of the Health Bill, moved by Lord Morris of Manchester, was debated at Committee stage in the House of Lords.

Lord Morris of Manchester: "For parliamentarians, there can be no higher duty than that of ensuring just treatment for those afflicted and bereaved by contaminated and life-threatening medication supplied by the state, and the emphatic backing of the report's recommendations by the mass media as a whole shows how clearly that duty is understood by the people of this country."

"It was just as clearly understood, too, by my right honourable friend Harriet Harman MP, Deputy Leader of the Labour Party and Leader of the House of Commons, when speaking on 5 March. Already having thanked my noble and learned friend Lord Archer, for his "important work", she told my honourable friend Dr Brian Iddon of her, "congratulations to the campaigners", on having, "brought to the public's attention the injustice that they have suffered", from contaminated NHS blood and blood products. She also made it clear to the House of Commons that: "The Government will respond shortly". Thus the Haemophilia Society now looks forward to a positive response to the landmark report that she so fulsomely welcomed.

Baroness Campbell of Surbiton: "The scandalously slow reaction by previous Governments to safeguard blood products imported from the United States meant that we failed to protect nearly 5,000 people who died or are now living with HIV/AIDS, hepatitis C or, now, CJD. The amendment proposes establishing a committee that will go some way to righting a great wrong which was done to those people. It is not a big initiative it is just a committee which would be a small, uncostly affair." (Column GC93-GC94)

Baroness Barker: "What I am most concerned about is that the Government's response should be timely and appropriate. It is a great shame that the Government did not contribute to the inquiry chaired by the noble and learned Lord, Lord Archer, but they are under an obligation to respond in a timely fashion. The government response perhaps needs to be in two parts: one an urgent response to the needs of people who are currently living with the consequences of being given these blood products, whose needs are urgent and serious, and the other on the wider question of what we should learn from the inquiry. That response would be much longer and more detailed." (Column GC94)

Earl Howe: "One of the things that I have learnt from the report is that there are too many haemophilia patients currently suffering hardship and serious distress as a result of this worst of all healthcare accidents in the history of the NHS. The Government have a moral obligation to give careful consideration to the report and to respond to its recommendations for the sake of those patients." (Column GC95)

Baroness Masham of Ilton: "A united committee could give support and information to those involved with this challenging speciality, which needs all the support it can get. This amendment may be the last on the Bill, but this is an important issue. The work with prions needs top scientists to find a way of protecting everybody from the dangers of contaminated or tainted blood. It could affect anyone at any time."

Lord Rea: "I have a quote from the report, which sums up the problem in a nutshell. Page 105 states:
"We must now look to the future. We cannot undo the damage done, nor turn back the clock to take a closer view of those past events and decisions. We must address the ongoing needs of those affected and consider how the state can ensure these citizens are recompensed.". This amendment does just that."

Source: Link #1
Type: Lords Hansard. 17th March 2009
Location: UK
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17 March
Lord Morris of Manchester on Crown Immunity and BPL
On Tuesday 17th March 2009, Lord Morris of Manchester made important reference to Crown Immunity and BPL (raised in the Archer report) during the Committee Stage debate of Amendment 133 of the Health Bill:


Lord Morris of Manchester: "The other issue to which I must finally refer is that of Crown immunity, on which the Archer report raises in commenting on behaviour of the Blood Products Laboratory (BPL). The report says:

In July 1979, the Medicines Inspectorate visited BPL. They reported that the buildings were never designed for the scale of production envisaged. They commented: "If this were a commercial operation we would have no hesitation in recommending that manufacture should cease until the facility was upgraded to a minimum acceptable level.".

"...The report then says: "BPL was rescued by Crown Immunity", and goes on to say that, "the existing plant continued production, relying on Crown Immunity to dispense with all the requirements of the Medicines Act, but was able to meet only about 40 per cent of the national requirements".

Lord Morris of Manchester: "Surely, words have lost their meaning if this does not mean that by the use of Crown immunity, a relic of feudal England, the lives of countless haemophilia patients were blatantly and gravely put at risk."

"...There could be no clearer text for describing the enormity of the use by the BPL of Crown immunity to dispense with all the requirements of that renowned and vital statute. I beg to move."

Type: Lords Hansard
Location: UK
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17 March
vCJD: Sombre Threat Now of a Third Scourge Facing the Haemophilia Community
On Tuesday 17th March 2009, in a House of Lords Debate on Amendment 133 of the Health Bill, Lord Morris of Manchester makes important reference to the threat of vCJD to the haemophilia community:

"There are two other issues to which I must briefly refer. The first is the sombre threat now of a third scourge facing the haemophilia community. I refer to the increasing number of haemophilia patients known by the Department of Health to have received blood from donors who subsequently died of vCJD, and the recently reported case of one hepatitis C-infected patient, a post mortem on whom revealed vCJD in his spleen."

"I was informed more than once on the authority of the Chief Medical Officer that the risk for recipients of blood donors who subsequently died of vCJD was purely "hypothetical"; but that demonstrably is not the case now."

"Is donated blood currently being screened, or filtered to remove vCJD infection? If it is not, can my noble friend in replying to the debate say what protection is in place to safeguard recipients of donated blood? I understand, and my noble friend will confirm whether it is so, that technology is now available to remove by filter the abnormal prions which are the causative agent of vCJD and that it has passed EU-wide safety testing and clinical trials as required for its use in the UK..."

"...The haemophilia community, like Members of both sides of both Houses of Parliament, are anxious to secure ministerial assurances of urgent and effective action in this policy area, and I look forward to my noble friend's response to the questions that I have raised."

Source: Link #1
Type: Lords Hansard
Location: UK
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