Infected Blood Inquiry: lessons to be learned

In the second of a series of articles on the Infected Blood Inquiry, we review the lessons to be learned to ensure we avoid complacency.

So, what, then, in addition to avoiding complacency, are these lessons?

Complacency is the enemy of safety

The start of the chapter on “Lessons to be Learned” is very powerful.

Sir Brian explains that it's clear from the first chapters of the Inquiry report onwards that most infections could and should have been avoided. It's clear that mistakes were made. The way in which institutions, and particularly the government, reacted to what had happened after 1985 was in many respects shameful. This should never happen again. The first step in deciding how best the mistakes of the past can be consigned to the past, and kept there, is to understand the lessons to be learned from what happened. One of the lessons is that wishful thinking is all too easy and should be avoided. It would be wishful thinking to suggest that because we can now see what combined to cause the greatest treatment disaster in the history of the NHS and recognise steps that need to be taken to guard against it happening again, that something similar will not do so.  

To ensure the greatest possible safety, we need to avoid complacency. There is no basis for assuming that threats are all in the past: but watchfulness and learning the lessons of what happened in the infected blood disaster are critical to this.

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