Addressing the issue of a cover-up, he said better wording was “hiding the truth”.

There had been a lack of openness, inquiry, accountability and elements of “downright deception”, including destroying documents.

But hiding the truth included not only deliberate concealment but telling half-truths or not telling people what they had had a right to know – including the risks of treatment they had received, what alternatives had been available and, at times, even the fact they had been infected.

Sir Brian said the scandal had destroyed “lives, dreams, friendships, families and finances”, adding the numbers dying were still climbing week by week.

“This disaster was not an accident,” he said.

“The infections happened because those in authority – doctors, the blood services and successive governments – did not put patient safety first.”

About 380 children with bleeding disorders had caught HIV after being given blood products for their condition, the report said.

Many had died in childhood or young adulthood, having endured a level of pain and fear no child or young person should ever have to face.

And some had been treated without them or their parents giving informed consent, which the report called unconscionable.