There's just so much, but this is a huge report, seven volumes, two and a half thousand pages. It covers 50 years of this disaster. But distill all that history down, there's a clear conclusion. This scandal was not an inevitability, and to a large degree, it was preventable. In his summary, the chair, Sir Brian Lange staff, finds, I have to report a catalog of failures which caused this to happen. Each on its own was serious. Taken together, there are calamity. He goes I have to report that it could be largely, though not entirely, have been avoided, and I have to report that it should have been. Why could it have been avoided? Well, one of the first conclusions that he makes is the Commission on Safety of Medicines, the body in the UK at the time, and even now, that's meant to stop products to make sure medical products are safe, should never have licensed these imported American products that were infected with hepatitis C and then later HIV. It finds the evidence available to the inquiry suggests that safety was not put first. Having considered all the available evidence, I ultimately have to conclude that decisions should not have been taken as they were.

They certainly should not have been left to individual clinicians to take. That risk was put on to individual doctors, and sure enough, they prescribed these medicines, thousands of hemophiliax were affected as a result. But there's a parallel tragedy going on here that we haven't really talked about so much yet. Our own blood supply in the UK wasn't that safe either. Tens of thousands of people are affected with hepatitis C. There were many organizations and individuals who were found to have acted wrongly in all of this evidence. Many are now dead, but one name that does get mentioned a few times is Kenneth Clarke. Now, Lord Clarke, he was the Health Secretary at a crucial time in the '80s when all this was going on, when HIV first arrived. The inquiry highlights his statement in Parliament. It was the government line at the time. There was no conclusive proof HIV was linked to these products and to blood. While technically correct, so Brian says, this was indefensible. It did not spell out the real risk. It gave false reassurance, and that was key. And he also highlighted the attitude of Ken Clarke when he gave evidence to the inquiry.

Saying that his inquiry, at times, his evidence was argumentative and unfairly dismissive. Have a listen to some of it.

Why do we have to go in such a meticulous detail through who said what, when, and when did he change his mind? And do you remember what actually persuaded you? It was just a frivole interesting, no doubt, but pretty pointless.

Perhaps the most damning conclusion overall, though, is the evidence there was of a deliberate cover-up by successive governments. A clear example that evidence key documents may have been deliberately destroyed around the safety of the UK blood cell apply, specifically. The evidence, subpoena says, is sensitive. It's hard to put a clear blame on any individual. But in one section, he states, Certainty is impossible, but it's an uncomfortable conclusion that it's more likely than not a civil servant chose to destroy the documents because they were those documents. He goes on to say that, If this is right, it was a deliberate attempt to make the truth more difficult to reveal. A big question, of course, for the survivors of this, for their families, will we get prosecutions? Inquiries are prohibited from finding civil or criminal liability. The survivors say whether they proceed with legal action depends largely on how the government responds on things like compensation in response to this damning report. Shocking on so many levels. Tom Clarke, thank you.