AT the end of its hearings, the hepatitis C tribunal is faced with the irony that, in this saga, it is doctors who have handed down life sentences and a judge who has the power to heal.

Nothing that Judge Thomas Finlay writes in his report will cure the physical harm done to over 1,500 people by the recklessness and arrogance of those at the top of the BTSB. But his findings can, nevertheless, heal the other breach of trust that accompanied that great wrong - the State's betrayal of so many of its people.

As he sits down to write a story that should have been told at least two years ago, Judge Finlay must bear in mind the double wrong done to the victims. They have been wronged both as patients and as citizens, both medically and politically. The judge's job is to account for each part of the disaster.

The medical side of the story is the most extraordinary, but also the easiest to assess. The report will set out for the first time the full extent of the terrifying breakdown of competence, judgment and moral responsibility in a State institution that once enjoyed the unquestioning trust of the public.

It is simply not open to Judge Finlay to find any excuses for the behaviour of those at the top, especially its medical directors between 1976 and 1995, Dr Jack O'Riordan and Dr Terry Walsh.

The report will have to show that these powerful and unaccountable doctors decided in the autumn of 1976 to ignore two of the most basic precepts of their profession. Their own rules told them never to make blood products from plasma taken from a donor who had received multiple transfusions, or from a donor who had jaundice.

They didn't just break each of these rules: they broke both at the same time. Such was their arrogance that they told neither the woman (Patient X) whose blood they were using to make anti D serum, nor her own consultant, that they were doing so. They treated her as a prospector might treat a mine, not as a person but as a source of raw materials.

THAT same mentality governed all their subsequent actions. Their concern was product, not people.

They seemed to see only the blood, never the human bodies and human lives through which it coursed.

When, in July and August 1977 the BTSB was told that cases of hepatitis were being found in real women who had been given antiD injections, it should have withdrawn all anti D made from Patient X's plasma.

Instead Dr Jack O'Riordan made a bizarre decision to stop using that plasma for making antiD but to carry on using the anti D already made from it. And when, in December 1991, Dr Terry Walsh and his colleague Dr Emer Lawlor were told that the 1976 and 1977 batches were definitely infected with hepatitis C, they did nothing about it.

This tunnel vision at the BTSB was not, however, underpinned even by the scientific competence that usually goes with technocratic arrogance. Prof Hans Hoppe, the scientist who developed the method the BTSB used for making anti D, gave evidence that the BTSB failed to keep up with his later modifications of it.

In the case of Patient Y, the second source of infected anti D, there was an appalling breakdown of basic procedures. In 1991, the principal biochemist at the BTSB, Mrs Cecily Cunningham, used plasma taken from her two years earlier to make anti D. Having asked for HIV and hepatitis B tests, she proceeded to make and issue anti D from the plasma long before the tests were actually done.

In her own words, "I just plodded ahead." Even when in October 1991, Patient Y's plasma twice tested positive for hepatitis C, the results were ignored. AntiD made with Patient Y's plasma continued to be issued as late as the summer of 1994.

The report will have to find that the scandal resulted from this fatal combination of haughty presumption on the one hand and shabby ineptitude on the other. And it should find that this amounted, not to an unfortunate series of errors, but to culpable negligence and a reckless disregard for human life. On the basis of that finding, the judge should recommend to Michael Noonan that the report itself be referred to the Director of Public Prosecutions.

Judge Finlay has to go on, however, to address the second kind of wrong done to the victims, the abuse of the trust that citizens place in their State.

He has to find first of all that there was culpable negligence on the part of the Department of Health as well as of the BTSB. For the evidence he has heard is that the Department colluded with the BTSB and the National Drugs Advisory Board (NDAB) in making a nonsense of the laws that were meant to protect the public.

The checks on the BTSB ought to have come from regulation by the Department and the NDAB under, firstly, the Therapeutic Substances Act (TSA) and, subsequently, under EU laws on product authorisation. Yet for 14 years between 1970 and 1984, the BTSB was allowed to make anti D without a TSA licence. And for the next 10 years, this passive attitude on the part of the Department of Health became one of active collusion in the evasion of the law.

Licences were backdated and notices of renewal sent out years after they had expired. A whole system of deception was put in place. And, most disgracefully, it continued even after the Department learned of the scandal. A bogus licence was issued just days after the BTSB admitted the disaster.

The Department was also negligent in its failure to authorise the introduction of routine screening of blood donors for hepatitis C until long after a test became available. Even more culpably, when it did decide to authorise the screening, it waited for four months before telling the BTSB that it had done so, a delay that resulted in at least six people contracting the virus from blood transfusions.

In the context of these failures, the report has to find that the Department's own role in the scandal contributed to its reluctance to make the full story public. It has to expose, yet again, the disastrous consequences of a culture of secrecy. And it has to find that two successive Ministers for Health, Brendan Howl in and Michael Noonan, played a part in the Department's failure to place the protection of the victims ahead of the defence of institutions.

IN the case of Brendan Howlin, the report has to record that a well intentioned minister never took command of the crisis that landed on his desk in February 1994.

While his initial decision to appoint an expert group rather than a public inquiry to investigate the scandal was perfectly justifiable, he should have reconsidered it when he learned that the expert group was being stymied by a lack of co operation from the BTSB. In the meantime, while the expert group was being blocked, Dr Terry Walsh was left in control of the crisis.

Brendan Howlin's only intervention in the BTSB itself was the appointment, over six months after the scandal broke, of a new chairman of its board. And not alone did he leave the problem in the hands of the very people who had caused it, but he failed to disclose the crucial information that the current stock of anti D in February 1994 was probably itself infected.

By never once mentioning the 1989 infection in any communication with the Dail, GPs, the victims or the public, he allowed his Department to proceed with a deliberate concealment of the full extent of the crisis.

The report should find that this was a contributory factor in the failure to withdraw all current stocks of anti D, in the relatively low number of younger women reporting for tests, and in the additional distress caused to the victims by the implication that those who received anti D in years other than 1977 must have contracted it through their own fault.

In Michael Noonan's case, the report should criticise his decision to publish the expert group report in the knowledge that it gave a misleading impression of the Department's role in the affair. It should also make it clear that his Dail and public statements before the establishment of the tribunal, denying that new evidence had emerged in the Brigid McCole court case, were founded on an utterly inadequate grasp of the difference between jaundice and infective hepatitis.

Michael Noonan's insistence that these terms were "synonymous" was contradicted by all the medical evidence before the tribunal. The effect of his vehement denials was to delay the establishment of a public inquiry and to increase the stress on the victims by forcing them to go to court to seek information to which they, and the public at large, were entitled.

For the victims there can be no justice, because nothing can make reparation for the harm that has been done to them. But if he sets out these conclusions clearly and forcefully, Judge Finlay can ensure that, even in the absence of justice, there can be truth.

Only by facing it without flinching can the State learn to recognise and to avoid the deadly consequence of professional incompetence, institutional arrogance and political failure.