A shortage of sterile water at a Dublin hospital in 1979 resulted in a haemophiliac being given an imported clotting agent which infected him with hepatitis C, it emerged at the tribunal yesterday.
The patient who became infected was Mr John Berry, a father of three from Athy, Co Kildare, who gave evidence to the tribunal last May and died in September. He received the contaminated clotting agent to stop a nose bleed.
Mr Berry's medical records, the first to be examined by the tribunal, showed that when he was examined at St James's Hospital in January 1979, having been transferred from the accident and emergency department of Naas General Hospital, his nose bleed had stopped.
However, it was noted that should it recur he should be given cryoprecipitate, a clotting agent made by the Blood Transfusion Service Board.
The nose bleed did recur at 6.45 a.m., and a note on his chart said there was "insufficient water for reconstitution of required dose of cryo precipitate", which was in powder form.
The notes added that a Dr Lawlor had ordered the use of two bottles of Hemofil.
Counsel for the tribunal, Mr John Finlay SC questioned Prof Ian Temperley, former director of the National Haemophilia Treatment Centre, about this. Counsel suggested that a junior doctor had sought advice on what to do when there was not enough sterile water available and was instructed by a more senior doctor, Dr Lawlor, to give Hemofil, a form of factor 8 concentrate manufactured in the US by the Travenol pharmaceutical firm. Prof Temperley agreed.
On the instruction to use Hemofil when there was no water, Prof Temperley said: "You might not feel it's appropriate, but it's the logical thing to do."
The records showed Mr Berry was given 560 units of Hemofil at 7.15 a.m., and bleeding stopped.
Mr Finlay asked if sterile water was not something that would be in constant supply in a hospital at that time. "Well, apparently it wasn't," Prof Temperley replied.
He added that the nose bleed occurred early in the day, "at an inconvenient and very awkward time of day", and it was quite possible the doctor could not find sterile water. "Sterile water per se would not necessarily have been a common form of fluid on the acute ward," he said.
Counsel said Mr Berry was a person with mild haemophilia, and there was no record of him ever receiving concentrated clotting agent before this. He asked Prof Temperley if there was a policy in place to give mild haemophiliacs cryo precipitate, an Irish product which would have been perceived as safer from the point of view of hepatitis as it was made from the blood of voluntary donors, or if safety was taken into account.
Prof Temperley said he did not believe this safety aspect was a major consideration.
Counsel asked why it was not taken into account. Prof Temperley said the increased risk of hepatitis from commercial product was known in 1979 but "not taken on board in any major way".
He said a policy on the use of cryoprecipitate for mild haemophiliacs was only forming then.
Mr Finlay suggested there should have been a policy in place. Prof Temperley said the perception in the Republic, the UK and the US at the time was the same. "I don't think policies were formulated regarding hepatitis at this particular time," he said.