LAST week saw the stairt o the UK public inquiry unner Sir Brian Langstaff intae the infected bluid scandal. This, as ye’ll ken, sairly affectit patients in Scotland an across the hale o the UK. It hus bin caa’d the “biggest single healthcare scandal” in the UK. It is tho anely pairt o an e’en bigger failure tae prevent hairm tae patients.

The infectit bluid is nou estimatit tae hae bin responsible fir aboot 3000 daiths in the UK, wi tens o thoosans o ithers aiblins infectit. The scandal stairtit in the 1970s wi infectit bluid bein bocht in frae the USA. Relative tae wirsels, the USA hus verra puir staundarts oan patient safety oweraa an didnae screen its supply o bluid. It taen the bluid it needit fir transfusions frae prisoners in their jyles an bi gettin the public tae sell their bluid. Notoriously, this supply includit intravenous drug uisers thegaither wi their range o infections sic as Hepatitis C and HIV. We, athort the hale o the UK, then failed tae test an treat the bocht-in bluid. A hale range o patients becam infectit, perteecularly haemophilliacs. Mony patients dee’d quite horrible daiths. This muckle scandal hus rumbled oan nou fir 30 years syne.

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Patients an faimilies in Scotland an rUK hae bravely focht fir decades tae get justice fir these murderous ongauns. At the hinnerend nou we shuid hae a rael inquiry that gies rael answers an solutions tae the victims – the yins still alive. Oor campaign group ASAP-NHS hus past experience o regulatin in the NHS, includin inspectin the bluid transfusion service in the wake o the scandal. We hae providit a submission tae the public inquiry. Oor report kythes that the scandal heppent acause the NHS athort the hale o the UK roup an stoup failed tae comply wi existin law that applied tae the control o infections; the Health and Safety at Work etc Act 1974. Baith the NHS an the UK Government failed tae identify whit shuid hae bin plain as pairritch an obvious risk. The then regulator o patient safety, the Health and Safety Executive (HSE), did naethin. They failed tae regulate, an still aye-an-oan 40 years later there is nae regulator o patient safety in Scotland. In the wey it manages risk the NHS is still in the Daurk Ages tae whaur the law requires it tae be.

Patients an faimilies experienced an saw the growin disater an sufferin as it unfoldit. Oan their ain they cuid dae dael-a-hate aboot it. But gradually they wir able tae organise an pit pressure oan the governments in the UK. The deceesion wis made that altho the law oan patient safety is UK-wide it wid be Scotland that wid rin the public inquiry. This wis caa’d in 2008 as the Penrose Inquiry, an it pruived tae be a judicial disaster.

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It reportit oan March 25, 2015. Baith the inquiry an its report wir byordnar puir, an it is yet baith an embarassment tae Scotland an tae oor legal profession. The people leeterally shoutit it doun. E’en sae, gin ye hae an eident luik the evidence o its 1861 pages propones that there wir avoidable delays in screenin an testin o bluid supplies, the ootcome o these failins wis thoosans o preventable daiths. The report identified serious fauts wi the Scottish National Blood Transfusion Service (SNBTS) at the time in its deceesion-makkin. Scotland wis gey late tae adapt screenin and testin.

The Penrose Inquiry totally failed tae conseider the law an legally-required regulation. This, fowks, is the law that gin it hud bin implementit, complied wi, and regulatit (as it shuid hae bin!) wid hae preventit the disaster; the thoosans o daiths, an verra sairious hairm tae ither patients. In a verra byordnar deceesion the report wis signed aff bi the Scottish Government in spite o its no makkin mention the statutory law. The HSE didnae e’en boathir tae attend the inquiry – sic wis the contempt they held the people in.

The inquiry taen seeven years, cost us aa £12 million (but heh, thon’s ok, it’s juist public money an they can pish as much o that up the wa as they like!) and ignored the views o the faimilies an the law. It failed tae realise whit the rael problems wir, produced wan uiseless recommendation, an failed tae prevent seemilar NHS tragedies wi the samen common cause. Aa in aa it wis a complete bourach; a waste o praicious time, public faith an public siller. The £12m cuid hae bin uised tae stairt creatin an effective patient safety regulator. It wis nae wunner that the faimilies set lowe tae the report, an brunt it oan the steps o the coort hoose. The hail jing-bang wis a travesty o Scottish justice. The final insult tae patients wha needlessly dee’d an their grievin faimilies.

This is juist wan o mony patient safety scandals in Scotland. Ae cause is the lack o legal competance. The Lord Advocate an his Crown Oaffice it seems cannae dae suspicious daiths in healthcare. There are the ongaun Tayside mental health an ither preventable daiths. There is the hairm tae dozens of patients unner the care o the surgeon Sam Eljamel (reportit bi BBC Scotland) whaur the board didnae manage his performance. There are the wan-a-day serious incidents aften involvin preventable daiths at NHS Lothian (currently bein investigatit bi Police Scotland). We hae new cases at NHS Ayrshire & Arran whaur the Lord Advocate refuses tae dae e’en the basics o an investigation. He e’en relies oan the wird o the main suspect! Whit’s tae be duin fowks?

History kythes that the Scottish people can anely be push‘t too faur. The motto oan the thistle reads “No one provokes me with impunity” – as the brave NHS whistleblowers at NHS Highland an NHS Grampian hae shown in the past week; we’ll mibbes no be push’t ony further.