AS HE faced questions in the Dail yesterday about the Blood Transfusion Service Board and HIV infection, the Minister for Health must have been aware of a certain irony.

Mr Noonan had been placed in a difficult position by the BTSB's unimpressive response to a risk of infection. He had been kept in the dark, not told until last week about a problem that has been present since 1985. He had been forced to go to the BTSB looking for explanations. The victims of the BTSB's infection of anti-D with hepatitis C would know exactly how he felt.

Their sympathy, however, must be tempered by Michael Noonan's part in the process by which they, too, were kept in the dark. And if the HIV episode suggests that the BTSB is not as yet a thoroughly reformed organisation, Michael Noonan must take some of the responsibility for that.

On July 21st, 1995, the Chief State Solicitor, acting for Mr Noonan, wrote to the solicitors for Positive Action (the pressure group formed by the women infected with hepatitis C by the BTSB) to warn them that any litigation they might take to the courts "will be fully defended by the State, if necessary to the Supreme Court".

This would, he warned, involve "uncertainties, delays, stresses, confrontation and costs" for the women. To avoid these unpleasant consequences, the women were to accept that they could have money but not an admission that the BTSB was liable, not an apology for the immense wrong done to them and not a full account of what had happened.

On September 20th this year, the BTSB's solicitors wrote to solicitors' acting for the late Mrs Brigid McCole, who was trying to bring out the truth through a High Court action, threatening to "seek all additional costs" from that date if she proceeded with her High Court action against the State.

It is clear from the letter that its threats were issued with the consent of the Department of Health.

AND yet, within the first few hours of the hepatitis C tribunal, which finished its first phase yesterday, the BTS implicitly accepted that it had, in reality, no defence to offer in any court case.

After a devastating recitation of agreed facts, many of which were disclosed to the public for the first time, the BTSB's counsel Donal O'Donnell SC told the tribunal the board "accepts responsibility for the events giving rise to the infection of anti-D with hepatitis C and its consequences and it does not seek to justify or excuse them". He went on to read out a long apology to the victims.

The difficult question for Michael Noonan, and for his predecessor Brendan Howlin, is why that admission and apology did not come long ago. Why, after the scandal broke in 1994, did the State not back to the hilt the demands for acknowledgment and redress made by its injured citizens?

Why did the Expert Group established by Brendan Howlin in March 1994 come up with a report that is now seen to be at best inadequate; and at worst misleading? Why were hard questions about what has gone on in the BTSB since the scandal became public not asked?

The first phase of the tribunal made it obvious that the BTSB never had a credible excuse for its failures. The tribunal heard a story that was deeply disturbing, at times almost unbelievable, but essentially simple. A body trusted by the public to provide, literally, a life-and-death service betrayed that trust.

It used a specific method for making anti-D, a product meant to protect the future children of the women who received it, but ignored the instructions of the scientist who devised that method. It laid down its own rules for the choice of donors but then chose on two separate occasions to ignore the two most basic rules by using plasma from a woman who had had multiple transfusions and who had been diagnosed as suffering from hepatitis.

Nothing thereafter made any real difference. Not an outbreak of hepatitis C among anti-D recipients in 1977 Not a series of positive tests in 1991 and 1992 on samples of blood from one of the women whose plasma was being used. Not a fax from Middlesex Hospital in 1991 pointing out that earlier samples had now proved positive for hepatitis C.

THE senior medical personnel at the BTSB during that period - Dr Jack O'Riordan and Dr Terry Walsh - had nothing to offer Mr Justice Finlay by way of explanation except loss of memory and abject contrition.

The second phase of the tribunal, however, will have to explore a more complex terrain, where questions of moral and medical failure shade gradually into questions of institutional and political responsibility. What will be at issue will be not what happened but why it was allowed to go on.

Did the board of the BTSB never understand what was being done? Did the Department of Health, which was and is represented on that board, ask any questions? Was the response of successive Ministers for Health to the scandal adequate to the depth of the problem that had been revealed?

Did Michael Noonan ever, for instance, try to ascertain how some very dubious information was given, and some very significant information was withheld, from the Expert Group? A "number of staff of the BTSB" told the group that a written report by a named Dublin consultant had explained an outbreak of hepatitis among anti-D recipients in 1977 as being due to "environmental factors".

Yet it seems that no such report ever existed: the BTSB could not produce it, the Expert Group was told by the named consultant that he had never investigated the incident and no evidence of such a report was given to the tribunal.

Rather disturbingly, current BTSB management told the Dail social affairs committee in June that it did not even know the names of the staff members who had told this story to the Expert Group, never mind questioned them as to how and why they had come up with it.

Yesterday, Michael Noonan told the Dail that the process of "renewal and re-organisation" in the BTSB will "require a further three to five-years of intense work".

Given the depth of the problems that have been revealed at the tribunal, that long timescale is understandable. What is less understandable is why it took over 2 1/2 years for the first condition of renewal - knowledgment and disclosure of what had gone wrong - to be fulfilled.

If We had done more to make that happen, Michael Noonan would be in a better position to fend off criticism over the latest episode in a very grim saga.