An inquiry into the infected blood scandal has pointed the finger at several people and organisations after more than 30,000 patients were "knowingly" infected with HIV or Hepatitis C.
Inquiry chair Sir Brian Langstaff said the "disaster was not an accident" and there was a "catalogue of failures" and a "pervasive" cover-up by the NHS and successive governments.
More than 30,000 Britons were infected with HIV and Hepatitis C after being given contaminated blood products in the 1970s and 1980s.
About 3,000 people died as a result, while many more still live under the shadow of health problems, debilitating treatments and stigma.
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Speaking after the report was published on Monday following the seven-year inquiry, Sir Brian said: "The damage caused was compounded by the reaction of successive governments, the NHS and the medical profession.
"Successive governments refused to admit responsibility to save face and expense.
"Today's report also found that the response to the infections made things worse, including repeated failures by governments and the NHS to acknowledge the victims should not have been infected in the first place."
In the report, he named specific people and institutions in his criticism.
They included:
Lord Clarke
Kenneth Clarke, now a lord, was heavily criticised by Sir Brian.
He was a health minister in Margaret Thatcher's government from 1982 to 1985, then health secretary from 1988 to 1990.
Lord Clarke was accused of being "somewhat blasé" when he gave evidence to the inquiry about the collection of blood from prisoners as late as 1983.
His manner was described as "argumentative", "unfairly dismissive" and "disparaging" towards those who have suffered, with Sir Brian saying he played "some part" in that suffering.
The report said it was "regrettable that he could not moderate his natural combative style in expressing views".
Sky News has approached Lord Clarke for comment.
Read more: 100 faces of infected blood scandal
The Thatcher government
Margaret Thatcher, as well as subsequent governments and health secretaries, continually said infections were "inadvertent" and patients were given "the best treatment available on the then current medical advice".
The inquiry report concluded that was not true and said the factual basis for the claim was unclear.
"In short, adopting the line amounted to blindness," the report said.
"Adopting it without realising it needed to have a proper evidential base, and they did not know what it was, was unacceptable.
"The line, which was wrong from the very outset, then became entrenched for around 20 years: a dogma became a mantra.
"It was enshrined. It was never questioned."
Sir Brian added that the Thatcher government "did not respond appropriately, urgently and proactively" to the risks of Hepatitis C and HIV transmissions through blood.
He said the government knew there was a much higher incidence of Hepatitis in prisoners, yet "no action" was taken to stop blood donations from them, which "increased the risk of transmission".
The failure lied "principally at the door" of the health departments in Westminster and Scotland, he said.
He said the Thatcher government signed up to recommendations in 1983 from the Council of Europe to inform clinicians and patients about the risks of treatment - yet failed to follow those recommendations.
Sir Brian described the failure to provide any guidance to doctors about the risk of transmission of AIDS as "inexcusable".
On compensation, he also said the Thatcher government "plainly formed the view, at an early stage, that nothing had been done wrong, and that no financial assistance would be provided to people with bleeding disorders who had been infected with HIV".
He added: "It did so without any proper investigation either into what had caused the infections or into the appalling plight of those infected."
Treloar School
Haemophiliac children were sent to the Hampshire school with an on-site NHS clinic so they could live as near a normal childhood as possible.
Instead, 75 boys died of AIDs and Hepatitis - and 58 were infected but survived - as they were included in secret trials to test a blood product called Factor 8, which was made with blood farmed from prisoners, sex workers and drug addicts in America.
The report said there "is no doubt" the risks of virus transmission were well known to doctors at Treloar School, yet doctors "played down the risks".
Some pupils and parents were "never informed" by the school the boys had tested positive for HIV, which Sir Brian said "was unconscionable".
Treloar School was a "microcosm" of much of "what went wrong in the way haemophilia clinicians treated their patients across the UK," he added.
The school said in a statement: "We are devastated that some of our former pupils were so tragically affected and hope that the findings provide some solace for them and their families."
It added that its management was "absolutely committed to exploring" calls for a public memorial to those affected, and added: "We'll now be taking the time to reflect on the report's wider recommendations."
Alder Hey Children's Hospital
The hospital was the main site in Liverpool for children with bleeding disorders from the late 1970s onwards.
Doctors used Factor 8 concentrate containing contaminated blood to treat them, even after other haemophilia centres stopped using them on children, Sir Brian found.
Alder Hey's director from the mid-1970s, Dr John Martin, "did not regard the risk of Hepatitis as a reason to alter any treatment regime", the report added.
"He exposed them to wholly unnecessary risks," it said.
Sky News has approached Alder Hey for comment.
Professor Arthur Bloom
Professor Bloom, who died in 1992, was one of the country's leading haemophiliac specialists during the period and treated some of those who were affected.
Sir Brian Langstaff said he "must bear some of the responsibility for the UK's slowness in responding to the risks of AIDs to people with haemophilia".
Prof Bloom said at the time he was unaware of any proof linking infections to the blood products and said there was no need to change patients' treatment, Sir Brian said.
He added: "Disastrously the Department of Health and Social Security was over-influenced by his advice, in particular his advice to continue importing commercial factor concentrates."
The NHS
Sir Brian said the response of the NHS and the government showed there was not a major plot to cover up failures "in an orchestrated conspiracy to mislead".
"But in a way that was more subtle, more pervasive and more chilling in its implications," he said.
"To save face and to save expense, there has been a hiding of much of the truth."
He also found patients were knowingly exposed to unacceptable risks of infection, with transfusions frequently given when not clinically needed.
The report also said there was no contact tracing exercise carried out when Hepatitis C screenings were introduced.
Sir Brian also said the NHS and governments repeatedly failed to acknowledge people should not have been infected, despite the scandal being known about.
Prime Minister Rishi Sunak on Monday offered a "wholehearted and unequivocal" apology to victims and said it was a "day of shame for the British state".
He said the findings of the inquiry should "shake our nation to its core" and promised to pay "comprehensive compensation to those infected and those affected."
The NHS said in a statement on its website: "Since September 1991, all blood donated in the UK is screened using very rigorous safety standards and testing to protect both donors and patients.
"Since screening was introduced, the risk of getting an infection from a blood transfusion or blood products is very low."
NHS England's chief executive Amanda Pritchard said she wanted to follow Mr Sunak's apology by doing "the same on behalf of the NHS in England now, and over previous decades".
She added: "I know that the apologies I can offer now do not begin to do justice to the scale of personal tragedy set out in this report, but we are committed to demonstrating this in our actions as we respond to [the report's] recommendations.
"While we work through those actions, we continue to work with the Department of Health and Social Care to establish a bespoke psychological support service for those affected, which will be ready to support its first patients later this summer."
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