IT WAS a wrong decision, wrongly arrived at, even in the context of information available at the time. "Isn't that the position?" asked Mr Justice Finlay. "Regrettably it is," replied Dr Terry Walsh yesterday. He was national director of the Blood Transfusion Service Board (BTSB) from 1985 until last year.
They were discussing a decision at Pelican House in 1977 which allowed anti D made from patient X's plasma, and that was still in stock, to be used, while at the same time it was decided not to use her plasma in making new batches of anti D. This followed hepatitis like symptoms in women who had received anti D in which patient X's plasma was used.
Dr Walsh also regretted "very much" that no one at the BTSB made the connection in 1977 between the anti D and that hepatitis like outbreak. "I've been very, very deeply upset by this," he said. He could not explain it. "I can only think people did not want to believe it," he speculated, "there was such faith in the product".
He agreed with Mr James Nugent SC, for the tribunal, that "there was enough evidence there to indicate a problem." It should have been investigated more thoroughly than it was. But the general belief of people in the BTSB at the time, including himself, was that the anti D was safe. "Did no one advocate it should be taken out of commission?" asked Mr Nugent.
"There was no opinion strong enough to change the view held."
"Everyone knew patient X had a problem?" "Yes."
"Everyone knew she had jaundice?" - "I can't remember it being put so cogently at the time, but it should have been.
"No one else looked at it?" - "I didn't and I regret I didn't ask more questions at the time." Earlier, Dr Walsh had agreed that as a patient who had received a number of transfusions it was wrong to use X as a donor. He knew the rule forbidding this. Questioned whether he knew patient X developed jaundice in November 1976 he recalled: "It is now apparent that I did know it. She should not have been used. I fully accept it was wrong to do it then, and fully apologise.
He was "totally unhappy" about his own response to the December 1991 fax from Dr Garson at the Middlesex hospital (which linked the patient X anti D to hepatitis C). He was "preoccupied with other matters".
"I am wholly and totally devastated by my lack of response at the time," he said. He regretted not drawing "what is now the obvious inference". It was why he was so shocked in January 1994, when Dr Joan Power had asked him whether there had been any problems with the anti D programme in Ireland. "I was horrified to realise I hadn't acted on the 1991 fax, and that there might be a bigger problem out there than I had construed."
He said the first time he had, heard that patient Y had tested positive for hepatitis C in July 1992 was "this week." He was "appalled by that. It didn't get to me at all".
He agreed he had told the Expert Group, which investigated the BTSB in 1994, that there had been only four cases of hepatitis like reactions in women who had received anti D between 1977 and 1994. He agreed that was wrong, but it was all the knowledge he had in 1994.
"What has happened in this tribunal that has caused your memory to revive?" Mr Nugent wondered. "A lot of the information that has come to light, has come post 1995," replied Dr Walsh.
