The doctor in charge of haemophilia treatment services in Cork admitted to the tribunal yesterday that she took no definite steps to withdraw a contaminated blood product after it was shown to have infected one of her patients with HIV.
Dr Paule Cotter conceded that an infectious batch of BTSB-made Factor 9 continued to be used in Cork until December 19th, 1985, a full month after one of her patients had tested positive from its use.
She also admitted that she failed to inform the relevant authorities of the infection so they could act upon it. This, she said, was not done deliberately. Rather, it was an "omission" on her part.
The patient, given the pseudonym Andrew, was the first haemophilia B or Christmas disease sufferer in the State to test positive for the AIDS virus.
Records from the Virus Reference Laboratory (VRL) in Dublin showed that the positive test was confirmed to Dr Cotter on November 14th, 1985.
The doctor said she believed this result followed a previous positive test in July 1985, which was returned around September, although there was no documentary evidence of this earlier test.
Records did show, however, that a negative specimen from February 1985 was retested and was confirmed to be negative on December 5th, 1985, proving that Andrew had sero-converted between the two specimen dates.
Dr Cotter agreed that the results showed BTSB Factor 9 had infected Andrew, as it was the only product he had used. However, the "huge significance" of this finding had not immediately impacted on her.
She said she had no distinct recollection of informing either the Blood Transfusion Service Board or the Department of Health of the sero-conversion. She did not know at the time that it was the first such in the State, only the first in one of her patients.
A total of seven haemophilia B patients were infected with HIV through non-heat-treated BTSB Factor 9 administered up to February 1986.
Asked whether she had informed Prof Ian Temperley, the medical director of the National Haemophilia Treatment Centre, of the positive test result, Dr Cotter replied that she believed she did, but was not sure when.
She admitted that it seemed "very obvious" in hindsight that she should have informed Prof Temperley and the BTSB of the case at an earlier stage. However, she was dealing with numerous test results at the time and, furthermore, she believed that the matter had been resolved by a recall, which she thought occurred around October 1985, of a batch of BTSB Factor 9.
Questioned about this alleged recall, of which - the tribunal heard - there was no documentary evidence, Dr Cotter said she believed someone from Pelican House contacted her by phone and within two minutes she would have passed on the information to Cork University Hospital's blood section.
She accepted, however, that the recall could not have related to the batch used by Andrew, as it continued to be used until there was none left.
Prof Temperley has given evidence to the tribunal that he was not told of Andrew's case until after he wrote to Dr Cotter in April or May 1986, asking her to repeat HIV testing on haemophilia B patients.
Counsel for the tribunal, Mr Gerry Durcan SC, said Prof Temperley's letter on this matter seemed to suggest that he did not know about Andrew's case.
Dr Cotter said that was one possible explanation.
Asked whether she told Prof Temperley about Andrew's case, Dr Cotter said she believed the patient's test results may have been sent independently by the VRL to St James's Hospital, Dublin, where Prof Temperley practised.
Mr Durcan asked why she had never made the "slightest suggestion" of this in 1 1/2 hours of evidence yesterday morning. Dr Cotter replied that she believed she had mentioned it.
