A damning landmark public inquiry concluded that the scandal could largely have been avoided and there was a pervasive cover-up to hide the truth. Inquiry chairman Sir Brian Langstaff described the disaster as a calamity.
More than 3,000 people died as a result of the scandal, and survivors were left battling for decades to uncover the truth. The inquiry found deliberate attempts were made to conceal the disaster, including evidence of Whitehall officials destroying documents.
Patients were knowingly exposed to unacceptable risks of infection. Sir Brian said repeated claims from successive governments that patients received the best medical treatment at the time were untrue.
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