The most important voices in the infected blood scandal have been and should remain those of the victims and their families. If it wasn’t for their perseverance, one of the greatest medical scandals in living history would not have been uncovered.

The thousands of lives lost and ruined by medical malpractice was bad enough in itself but what followed makes this scandal scarcely believable. It was a widespread conspiracy to cover-up the malpractice after.

The PM called it “a day of shame for the British state” but the release of the 2,527-page report from the Infected Blood Inquiry should be so much more than that. It should be a day of reckoning across public institutions and government.

It should be used to reinforce the values of public service and the duty of care that comes with positions of power.

Victims and campaigners outside Central Hall in Westminster, London, after the publication of the Infected Blood Inquiry report. PIC: Jeff Moore/PA Wire

The experience of victims is heartbreaking. One of Mel McKay’s earliest memories is of a teacher at school shouting “don’t touch her” after she fell. She was a little girl when she was given a transfusion which left her with HIV. That is just one example of the human impact this scandal has had, an impact that should never be forgotten.

While this scandal highlights widespread political failings, Hull North MP Dame Diana Johnson should be praised for taking up the cause on the behalf of victims. Ms McKay even refers to her as campaigners’ “saving grace”.

As David Behrens writes in The Yorkshire Post today, organisations such as the NHS need to put an end to the culture of institutional defensiveness.

The NHS isn’t a golden goose that must be constantly fattened up. It isn’t sacred. It can and does get things wrong. This scandal shows that better governance and management needs to be put in place.

The testimony of the victims of the infected blood scandal is heartbreaking

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