The inquiry concluded that the contaminated blood scandal in the United Kingdom could and should have been avoided.

The scandal surrounding the use of contaminated blood in the United Kingdom was not an accident, but rather a mistake by doctors and several governments, an investigation concluded this Monday.

In the 1970s and 1980s, more than 30,000 people were given contaminated blood and blood products by Britain’s publicly funded National Health Service, with 3,000 dying and thousands contracting hepatitis or HIV. In some cases, blood products obtained through donations from American prisoners or other high-risk populations have been used to treat children by infecting them with HIV or hepatitis C long after the risks were known.

Inquiry chairman Brian Langstaff said the government had covered up the truth to “save face and save money” and added that victims should now be “adequately compensated”.

“This disaster was not an accident,” Langstaff said. “The infection occurred because those in charge – doctors, blood services and successive governments – did not put patient safety first.”

The use of contaminated blood has caused thousands of deaths in the United States, France, Canada and other countries.

British Prime Minister Rishi Sunak said the day the inquiry’s findings were published was a day of shame for the British state, which included ministers, government officials and people working in the health sector. “This is a day of shame for the British state. The results of this investigation should shake our nation to its core,” Sunak told parliament.