Signal failure by health authorities to achieve self-sufficiency in blood products triggered the wave of deaths among haemophiliacs in the UK, an independent inquiry has held.
In the 1970s and 1980s blood derivatives were sourced from within the UK and from the USA. Many blood donors were found to have funded their drug habit through the payments obtained from selling their blood. Predictably the blood products procured from such sources were found infected by Hepatitis C and HIV.
Nearly 2,000 haemophiliacs have died as a result of exposure to the contaminated blood. Leading medical expert Lord Winston called it "the worst treatment disaster in the history of the NHS".
Some 4,670 patients who received blood transfusions in the 1970s and 1980s were infected with Hepatitis C, of whom 1,243 were also infected with HIV.
Earlier this week the Health Protection Agency confirmed the death of the first haemophiliac to have contracted vCJD from contaminated blood although this did not cause his death. The donor died six months after giving blood in 1996.
All patients with bleeding conditions were told in 2004 that they were at risk of having contracted vCJD from contaminated products that were administered between 1980 and 2001.
A privately-funded inquiry into the tragedy was set up two years ago by Lord Morris of Manchester, president of the Haemophilia Society, after decades of campaigning from victims and their families.
The inquiry was led by Labour peer Lord Archer of Sandwell.
Former health minister Dr Lord Owen has given evidence along with patients, doctors and advocates.
In their report submitted Monday, the team said the infection of so many people was a "horrific human tragedy."
The authors of the report said they were "dismayed" at the time taken by the Government and scientific agencies to respond to the dangers of Hepatitis C and HIV infections.
"The haemophilia community feels that their plight has never been fully acknowledged or addressed," they said.
There was "lethargic" progress towards national self-sufficiency in blood products in England and Wales, where it took 13 years compared to just five years in Ireland.
As a result the NHS bought blood from US suppliers who used what became known as "skid row" donors, such as prison inmates, who were more likely to have HIV and Hepatitis C.
The report said: "It is difficult to avoid the conclusion that commercial interests took precedence over public health concerns."
It added: "Whether the lack of urgency over much of this period arose from over-hesitant scientific advice or from a sluggish response by Government is now difficult to assess."
The authors said a full public inquiry into the scandal should have been held much earlier to address the concerns of haemophiliacs.
In conclusion they said: "Commercial priorities should never again override the interests of public health."