UK Prime Minister Rishi Sunak apologized “wholeheartedly” to every victim of the country’s infected blood scandal after the final report of an inquiry into contaminated blood transfusions was released Monday. He cited the report’s conclusions that British authorities, including successive governments and the National Health Service (NHS), were guilty of a “catalogue of failures” and a “pervasive” cover-up over decades. Chair of the inquiry, Sir Brian Langstaff, said that the “disaster was not an accident” and has called for a compensation scheme to be implemented within a year.

The inquiry, which lasted five years, was prompted by the fact that between the 1970s and 1980s, more than 30,000 British people were infected with HIV and Hepatitis C after they were given contaminated blood treatments and transfusions, with approximately 3,000 dying as a result. Many more continue to suffer from chronic health problems and stigma.  The inquiry examined over 50 years of decision-making procedures before, during and after the infection of these 30,000 people and asked why “men, women and children in the UK were given infected blood and/or infected blood products; the impact on their families; how the authorities (including government) responded; the nature of any support provided following infection; questions of consent; and whether there was a cover-up.”

In the final report released Monday, Sir Langstaff reported that the scandal “could largely, though not entirely, have been avoided. And I have to report that it should have been.” He asserted that the report had to highlight “systemic, collective and individual failures to deal ethically, appropriately, and quickly, with the risk of infections being transmitted in blood,” as well as in handling the infections once their risk became apparent. He also placed paramount importance on the repercussions for thousands of families affected by the failures.

Langstaff outlined the unacceptable levels of risk and complacency on the part of authorities, with blood products continuing to be imported both domestically and from abroad from high-risk donors, including from prisons in the UK and the US, where prisoners and drug addicts had been paid to give blood. Licensing authorities failed to recognize that these blood products were unsafe and governments delayed introducing universal screening of blood donations for HIV “despite it being urgent (it was a public emergency) to begin this.” Even though the risks had been known since 1982, it took until the end of 1985 to use heat-treating (used to eliminate the HIV virus in blood donations), and the government ignored the UK’s Communicable Disease Surveillance Centre (CDSC), which wrote a letter to the then Department of Health and Social Security (DHSS) advising the withdrawal of all blood products made from blood donated in the US after 1978 from use until “the risk of AIDS transmission had been clarified.” The UK was one of the last developed nations to begin the testing of all blood donations directly for the presence of Hepatitis C.

The inquiry also looked at whether there had been a cover-up on the part of authorities in the UK, with Langstaff describing it as “hiding the truth,” which he said included “not only deliberate concealment but also a lack of candour … and failing to tell people about the risks inherent in treatment or the alternatives to that treatment, that they had been tested for infection, or been used in research, or were suffering from a potentially serious and fatal disease.”

The report made 12 recommendations, which include a compensation scheme, national recognition of “the worst treatment disaster in the history of the NHS,” changing the culture of the NHS so that “safety is embedded as a first principle and is regarded as an essential measure of the quality of care.” He emphasized the importance of ending a culture of defensiveness in the Civil Service and government, and how “the existence of a clearer, more emphatic, duty of candour among civil servants might have altered the nature of the government response.”

Speaking in the House of Commons, leader of the opposition, Keir Starmer, said: “As well as an apology, I also want to make clear we commit that we will shine a harsh light on the lessons that must be learned to make sure that nothing like this ever happens again.” Prime Minister Rishi Sunak, in a rare moment of cross-party accord, thanked Starmer for his “collegiate tone” and said “He’s right, it is irrefutably clear injustice has been done, that’s why I apologise wholeheartedly to everyone affected by scandal – the anger and sorrow across this House is the right response.”

The government is expected to set out the compensation scheme on Tuesday.