elimination wasn't risk even if full elimination wasn't yet possible. infections could have been prevented and lives could have been prevented and lives could have been saved even ifjust some of the measures examined in the report had been implemented. and if patient safety was the guiding principle, there should have been curiosity before 2017 about what led over 3000 people died and thousands more to live with infections. apart from lessons which should be learnt, what else should happen next miss well, i fully expect the government to make an apology. applause to be meaningful, though, that apology must explain what the apology must explain what the apology for.

applause it should recognise and acknowledge notjust it should recognise and acknowledge not just the suffering it should recognise and acknowledge notjust the suffering but it should recognise and acknowledge not just the suffering but the fact that the suffering was the result of errors, wrong is done and delays incurred. it should provide vindication to those who have waited for that for so long. applause and it should be accompanied by action. applause action obviously to recognise and remember what happened to so many people and to learn from the

inquiry. action to implement recommendations i made over one year ago... applause to set up a proper compensation scheme. applause a major task is the further work to be done in each of the four health services, to put patient safety at their heart. now, ensuring patient safety culture is not an easy task. inquiry after inquiry has recommended it and it has not been achieved as yet. what i recommend is that where an individual is responsible for something going wrong that was or might have been harmful, they should not usually be

blamed for owning up. owning up enables patient safety to be better achieved, after all. but they should certainly be blamed if they keep silent. applause they should be obliged to report near misses as well as actual wrongs. leaders in health care should be made subject to a statutory duty of candour where they are not already. applause and should be made accountable both for ensuring that duty is observed by those they lead and for recording and properly considering reports of concerns made to them. the regulatory landscape for patient

safety should be de—cluttered so that patients, and for that matter health care professionals, no way to take any concern they may have and leaders know exactly what is expected of them. learning from other safety critical enterprises and industries, the nhs should establish a safety management system. i highlighted in my recommendations the work on patient safety being led in england by the health services safety investigations body. all of this should be informed by developments and the digitisation of patient records. i have also recommended measures to end a defence of culture in the civil service and government. to do this, i have encouraged the government to reconsider whether, in the light of the facts revealed by this inquiry, it is sufficient to continue to rely on the current non—statutory duties in the civil

code of this code and ministerial codes to defend the defence of culture in the civil service and government. applause —— in the civil service code. in particular, i recommend that there should be a statutory duty of accountability on senior civil servants... applause for the candour and completeness of advice given to permanent secretaries and ministers and for the candour and completeness of their responses to concerns raised by members of the public and by their own staff. i recommended measures to make sure that people who have been infected with hepatitis c from blood transfusion or blood products have the monitoring for further limit damage

—— liver damage that they need and recommends that gps get newly registered patients if they have ever had a blood transfusion to try and find more of the people as yet undiagnosed. applause that is of course in addition to the free postal testing now available in england and wales. if there is anyone who is listening online to this who feels that they need that test, that is where they can currently get it. amongst measures i made to improve the safety of transfusions is action to outcome of every transfusion and to increase the use of alternatives to blood or blood products where possible. there are measures i recommend to protect the safety of haemophilia care. this

inquiry has aimed to listen and i hope it has succeeded in that. but listening is notjust for inquiries or courts. i recommend measures to empower the patient voice so that it is heard and taken seriously in day—to—day health care. in particular, that clinical audit should, as a matter of routine, include measures of patient satisfaction or concern and that the results are reported to the board or body concerned. i have recommended funding for patient advocacy and the particular consideration should be given to meeting the needs for people with sickle cell disorder or thalassaemia. applause another damaging failure to hold a

public inquiry when one is clearly merited must be avoided. though i recognise that the power to call an inquiry remains with a minister under the inquiries act, i believe there is a role here for the public and constitutional affairs committee, that is a select committee, that is a select committee of the house of commons, to consider whether to recommend to a minister that they should exercise their power and that if the minister disagrees with the committee, they must set out in detail and publish reasons for this disagreement sufficient to satisfy the committee that the matter has been carefully and properly considered. my final recommendation considers the question of implement in the recommendations i have set out. i have written to the minister to tell him that i cannot as yet notify him that the inquiry has fulfilled its terms of reference. those terms include the nature, adequacy, and

timeliness... applause of the response of government. as i have said repeatedly in public, delay not only causes frustration but it compounds the harm and suffering many of those infected and affected have enjoyed. in the context of this inquiry, perhaps beyond all other, it is unconscionable to allow a state of affairs to exist in which people's fears that the lessons and recommendations of this inquiry will collect dust on a cabinet office sheh collect dust on a cabinet office shelf are realised. i'm satisfied that i must do what i properly can within my powers to try to ensure that it does not happen. now, it is for the government to respond, as it

will, but i intend to use my position as far as i properly can to prevent any unreasonable delay in its doing so. applause i hope to be able to say soon that the inquiry�*s work is completed. applause after that, i recommend that the public and constitutional affairs committee should review both the progress of the government has made towards responding to the recommendations of the inquiry and if those recommendations are accepted, towards implement in them. finally, i would like to thank again

all of you here and all of those of you who are watching remotely for your contribution to this inquiry. whatever your perspective has been, the sheer numbers here pay testament to the importance of the issues this inquiry has been considering and it pays tribute to the interest and engagement which you have shown which has never flagged engagement which you have shown which has neverflagged since engagement which you have shown which has never flagged since the days when so many of you came to the preliminary hearing. an inquiry serves its purpose best when everyone involved, from whatever perspective, participates, as you have done. but i would like to thank, too, those who have contributed who would be here but can no longer be. too many are two seriously ill as a result of their

infections. too many have died. applause i will mention one person but everyone here knows of others who haven't survived to hear the outcome of this inquiry. perry evans gave evidence on the very first day of the inquiry�*s hearings in 2019. he had mild haemophilia and lead an active life, treated only with cryoprecipitate before factor products were introduced. he was diagnosed with hiv in 1985 and told he had two to three years to live. he survived. but he was diagnosed with an hiv cancer in 2002. he

survived but was in a coma for ten daysin survived but was in a coma for ten days in 2008 and wasn't expected to live. he survived. although with a range of health problems associated with hiv and hepatitis c and the treatments he had received. but very sadly, perry died exactly five weeks ago. his wife heather is here today. applause you don't need me to tell you more people die each week. imagine the difference it would have made if this inquiry had been held 30 years ago.

this inquiry had been held 30 years auo, , . this inquiry had been held 30 years aio, �* , . ., ago. justice now! applause - applause if people were given answers then, they had recognition of their losses so they could have lived the rest of their lives free from financial hardship without having to fight for justice and recognition. it may be late, but it is not too late. now is the time, finally, for national recognition of this disaster. the proper compensation and the vindication for all those who have been so terribly wrong. applause —— wronged. concentrates when the leader... had advised against it. that is what my report amounts to.

thank you. applause and there you have it. i have to say, i have watched a lot of speeches after inquiries and that has to be one of the most powerful and rousing i've ever seen. sir brian langstaff getting a standing ovation as he wraps up his speech on the day that he released his findings from the infected blood inquiry that he oversaw. just look at the people in that room. many have been waiting for decades for him to say what he said today. you are watching bbc news. we are live in central london outside the westminster methodist hall where we have just heard from sir brian

langstaff who chaired the infected