THE Department of Health should have adopted the "lookback programme" recommended by hepatitis experts in 1994. And its failure to do so represented inadequate and inappropriate supervision of the BTSB.
This was the strongest criticism in the tribunal's chapter on the Department's supervision of the BTSB.
The programme to trace recipients of contaminated blood and blood products was recommended to the Department's chief medical officer by the Group of Hepatologists in July 1994.
The report says the Department "should have specifically directed the adoption of the programme as proposed by the Group of Hepatologists. The failure to do so constitutes an inadequacy and inappropriateness of supervision."
On the screening programme it finds the communication between the Department and the BTSB on the screening and lookback prograrnme "adequate".
But it criticises the Department for not insisting on "a more complete recall including the physical recapture of the doses; and ... an immediate checking and reporting to the Department literally in a matter of days of the successful completion of the recall".
The Department was informed in July 1994 that several batches of the infected anti-D had slipped through. "It does not appear that the Department reported that fact to the Minister who says that he has no recollection of being so informed although further queries were raised by the Department," Mr Finlay says.
The actions of the Minister for Health and the Department were "adequate and appropriate" on the replacement of anti-D with a Canadian-manufactured product.
It calls the decision to retain Mr Ted Keyes as chief executive past his retirement date a "wise decision" due to pressures on BTSB staff. "There is much evidence that, the morale of people working in the BTSB was completely shattered in February 1994."
The appointments of Prof Shaun McCann as national medical director and Mr Liam Dunbar as chief executive were "immensely wise and advantageous steps for the Minister to take".
The then Minister for Health, Mr Howlin, is exonerated for the decision to wait for the results of a study of the BTSB by the Experts
Group and an outside consultant before reorganising the BTSB.
The report finds the response to women's problems with counselling were "adequate and appropriate". The representative group, Positive Action, had complained that counselling should not be conducted by the BTSB as it was the original source of the infection.
The Department's role was "inadequate" in informing sufferers of the existence and arrangements between itself and Positive Action. The report vindicates the "no fault" status of the compensation tribunal, saying it was the best possible system to get compensation to victims quickly.
And it says Mr Howlin's decision to set up an Expert Group in March 1994 rather than a judicial inquiry was an "adequate and appropriate response to the problem of trying to find out what actually had happened in regard to this infection of anti-D".
It further exonerates Mr Howlin for his second refusal to set up a judicial inquiry after the expert group reported inadequate co-operation from the BTSB in June 1994. "To have set up a judicial inquiry at that time would have been quite inappropriate," it says.
It then exonerates Mr Noonan for his refusal to set up an inquiry after the revelation of the "lost file" on Patient X.
This file, which showed Patient X had been diagnosed with infective hepatitis and not just jaundice, was revealed by counsel for Mrs Brigid McCole.
Mr Finlay calls Mr Noonan's refusal "quite adequate and appropriate"
