5y5temic individual failures to deal ethically, appropriately and quickly to deal with the infections and blood when the risks materiali5ed and the consequences for thousands of families. He says the scale is horrifying with this estimate of more than 3,000 deaths attributed to infected blood and blood products. I could go on taken quote5 like this. The di5aster wa5 could go on taken quote5 like this. The di5aster was not an accident, patients were knowingly expo5ed the di5aster was not an accident, patients were knowingly exposed to unexpected unacceptable ri5k patients were knowingly exposed to unexpected unacceptable risk of infection. There were repeated failures by governments and the nhs to acknowledge that patients should not have been infected. There was an absence of any meaningful apology. The repeated use by government of inaccurate and Defensive Line5 the repeated use by government of inaccurate and defensive lines to take including truly telling people that they had receiv