Seanad Éireann - Volume 150 - 26 March, 1997

Tribunal of Inquiry into the Blood Transfusion Service Board: Motion.

Mr. Manning: I move:

That Seanad Éireann,

(a) notes the Report of the Tribunal of Inquiry into the Blood Transfusion Service Board (BTSB) and acknowledges the gravity of the findings made against the Blood Transfusion Service Board, its servants and agents;

(b) accepts in full the recommendations of the Report;

(c) fully understands the extraordinary anguish and distress experienced by the victims and their families;

(d) notes and acknowledges the widespread sense of public outrage at the matters disclosed in the Report;

(e) supports the Minister for Health's request to the BTSB to make known its position on liability in all outstanding cases forthwith, in the light of the findings in the Report;

(f) supports the Government's intention to reappraise and amend the Scheme of Compensation and its Terms of Reference, including the question of whether the Tribunal should be established on a statutory basis in the light of the Report, the reappraisal to take place following consultation with representatives of the victims and with the Chair of the Compensation Tribunal, and consideration of any necessary legal advice;

(g) notes the Government's decision that the benefits of any adjustments to the Compensation Scheme will be made available to all victims, including in particular cases which have already been determined by the Tribunal, or which will be determined between now and the date any adjustments are put in place; and

(h) notes that the Government will not seek to resile from or repudiate any of the findings of fact in the Tribunal Report in any proceedings either in Court or before the Compensation Tribunal.

Minister for Health (Mr. Noonan, Limerick East): Before I deal with the terms of the motion I feel it incumbent on me to make a number of points of relevance. First, I know that I speak for everybody in this House and throughout the [1166] country, regardless of political affiliation, when I say that it is almost impossible to come to terms with the enormity of the scandal surrounding the hepatitis C infection of the anti-D product and the blood supply. Notwithstanding our best efforts to do so, I believe it will take a considerable length of time for all of us to comprehend fully the horrendous effect which this scandal has had, and continues to have, on the health and everyday lives of innocent victims and their families.

I truly believe that no words of mine, or indeed of any previous holder of the office of Minister for Health, can ever adequately apologise to the 1,600 women and men for the damage done to them by a system in which they had previously placed their fullest trust and confidence. Trauma and fear have been engendered in many innocent people by this experience. Yes, there is some recompense in the recognition that grievous wrongs were committed. Yes, there is some recompense too in the unequivocal allocation of responsibility for these wrongs by the tribunal of inquiry. There is some minor recompense also in the monetary awards to the affected victims — awards which we can only hope alleviate the suffering and distress expressed so heartrendingly by the victims and their immediate families. However, nothing can ever fully or irrevocably compensate them for being infected with hepatitis C — a condition for which, as yet unfortunately, there is no cure.

The formidable task of disentangling the complex facts of this tragedy, of putting order on them and setting them out plainly in language which precisely and exactly conveys the awfulness of these events, was entrusted by the Houses of the Oireachtas to Mr. Justice Finlay and has been discharged by him with unprecedented efficiency and expedition, for which I wish to record my thanks, the thanks of the Government, and, I am sure, of this House. The result of the House's decision to establish the tribunal is that there is now available for all who wish to avail of it — victims, participants, politicians, doctors and the public — a clear and coherent account of this matter, who is responsible and what is now to be done. The truth has been laid bare, a number of recurrent controversies laid to rest and responsibility allocated in a fair, just and impartial manner. It does not make happy reading.

No citizen, be he or she victim or participant in the events described or a mere concerned observer, can fail to be moved and humbled by the account of the distress and fortitude of those who have suffered and continue to suffer from the events described. The report gives us a coherent account of what occurred and why, but it is considerably more than merely a history. It is an unemotional indictment of past procedures at the BTSB and is unequivocal in its apportionment of blame to certain named members of staff. It offers a welcome and succinct illumination on a number of difficult legal issues — for example, the application of the Therapeutic Substances Act, 1932.

[1167] However, it also looks to the future. From the victim's point of view it sets out the factual basis upon which their claims for compensation, either in court or before the tribunal, will henceforth be based. The State will not seek to repudiate or resile from any of the tribunal's findings in any such forum. From the point of view of the blood supply it sets out a number of important recommendations, all of which have been accepted in full. The exceptional command of the facts exhibited by Mr. Justice Finlay lends to his recommendations an authority and a widespread acceptance that ensures the implementation of his recommendations in full will provide a sound basis for restoring full confidence in the blood supply.

I cannot allow this opportunity to pass, however, without commenting on the most recent incident involving the BTSB, namely, the contacting of an infected victim with a view to obtaining blood. Mistakes such as these, even when there is no risk to the blood supply, are simply unacceptable. I have made my views known trenchantly to the chairman and chief executive of the BTSB; and while I accept that great strides have been made in reforming the operations of the BTSB, it must be fully recognised that this latest incident has added to the negative perception of that organisation which the current management has done so much to dispel. Notwithstanding the real difficulty people may have in coming to terms with what has happened, the truth is that we need blood, our hospitals need blood and it is grossly irresponsible to call for the closing down of the BTSB or for the sacking of a public servant who has devoted such an enormous amount of time, effort and dedication to resolving the problems of the BTSB. Undoubtedly, mistakes can occur; but I will not be satisfied until such time as we can with total confidence rule out even the most minor error, because each such error, no matter how small, can undermine confidence in the BTSB.

Huge strides have been made to improve standards at the BTSB. The work of Mr. Liam Dunbar and Professor Shaun McCann has been invaluable in reorganising the BTSB and in setting and implementing new standards and procedures which ensure that the mistakes of the past will not recur. Management has drawn heavily on the recommendations of the Bain consultancy report in forming a strategic plan, much of which is already implemented. The acceptance of recommendations in Mr. Justice Finlay's report will further improve standards at the BTSB.

I would like to deal with these recommendations in some detail because they are important for the future. I have already stated publicly that the Government accepts in full the recommendations of the report. These recommendations will be implemented as quickly as possible. The report makes six significant recommendations in relation to the future workings of the BTSB and the Irish Medicines Board. Those portions of the [1168] development plan for the BTSB for the period 1996-99 which have not yet been implemented will be implemented without delay. I will ensure that the 1999 target date for completion will be met. In particular, I have approved the relocation of the art headquarters of the BTSB from Pelican House to a new site on the campus of St. James's Hospital. This new building will ensure that state of the art laboratories, including all the necessary equipment and staff, can be put in place to ensure that our national blood service will have the required range of facilities to carry it through to the 21st century. The renewal or replacement of the BTSB unit in Cork will be commenced immediately. The estimated capital cost for the completion of the development plan is £20m.

The tribunal has made detailed recommendations in relation to the monitoring of the BTSB by the Irish Medicines Board. In response to the expert group report of April 1995, I have given the Irish Medicines Board statutory responsibility for the inspection of the collection, screening, processing and quality control facilities and procedures in respect of blood, blood products and plasma derivatives with a view to ensuring their safety and quality. The tribunal has recommended that the Irish Medicines Board should carry out at least two full inspections of the BTSB each year. This has already been implemented in that the arrangement is that the IMB carries out four inspections of the BTSB each year. My Department has commenced discussions with the Irish Medicines Board with a view to implementing a recommendation that it should be required to make an annual report to the Minister, for publication, on the outcome of these inspections and also on any reports received by the IMB of abnormal reactions to blood or blood products from any person or institution.

The tribunal has recommended that there should be a statutory obligation on medical and nursing personnel to report contemporaneously all abnormal reactions to blood or blood products both to the IMB and the BTSB and that the BTSB should also be obliged to report to the IMB on all abnormal reactions of which it becomes aware. The tribunal also recommends that failure by any employee of the BTSB to report such abnormal reaction if committed intentionally or by gross negligence should be a criminal offence. I am accepting this recommendation. There are potentially difficult legal issues which will have to be teased out in the course of its implementation and I have already instructed my Department to proceed immediately with this work.

A blood service consumers council, including representation from those who regularly receive blood and those who regularly donate blood, will be set up in the immediate future. This will make a major contribution to the maintenance of public confidence in the supply of blood and blood products. I believe it is vital that members of the general public should have an advisory role in the BTSB.

[1169] The report of the tribunal is critical of the recall of the anti-D product undertaken by the BTSB in 1994 and has recommended that the BTSB should forthwith prepare a new standard operating procedure for a recall of any product, the safety of which is suspected. I have instructed my Department to commence the process of implementing this recommendation with the BTSB.

The tribunal has also looked at the difficulty which could arise if it was again necessary to stop using a particular blood product at short notice but there was no product authorisation in place for alternatives which could be imported quickly as an emergency replacement. The tribunal points out that a commercial undertaking may not be concerned to undergo the trouble or expense to obtain a product authorisation on the off chance that its supplies may be needed in an emergency. The tribunal has asked that a possible solution should be considered whereby the present regulations would be amended to provide for what it terms “standby” or “emergency” product authorisations to cover such situations. This is a most worthwhile suggestion which I have instructed my Department to investigate without delay. I accept the tribunal's recommendation that if such a scheme is feasible the BTSB should be required to make use of it so that “standby” authorisations will be in place for products such as anti-D and factor VIII.

The implementation of the tribunal's recommendations will build on the work already undertaken by the new management in the BTSB to ensure as far as possible the safety of blood and blood products into the future. The necessary groundwork has already been put in place by the new management of the BTSB over the past two years in respect of many of these matters.

Hundreds and thousands of people in this country have given freely over decades millions of donations of their blood in order to maintain, sustain and extend life for those critically ill or critically injured. Our blood supply system in this country is among a small handful of unique voluntary blood supply systems. I appeal to people on all sides of this House to approach the current debate on how best to protect and promote the integrity of the national blood supply with humility, with a sense of proportion and balance and with a real sense of responsibility for a public duty in its broadest meaning. In the interest of the nation Members on all sides of this House, while exercising their absolute right to scrutinise all Government policy at all times, will accept that the voluntary blood supply is a national asset which should not be unfairly exposed to partisan politics, whatever about particular criticisms.

I met recently with representatives of Positive Action in response to a letter which they sent to me on 14 March last outlining their views arising from the publication of the tribunal report. Positive Action has requested a full reappraisal of the compensation tribunal. The reappraisal upon [1170] which the Government is embarking is principally required because our knowledge has been altered by the publication of this report.

The Government has decided to place the compensation scheme on a statutory basis, but has resolved that the operation of the compensation tribunal should not be disrupted or delayed while the scheme is being prepared and the statute drafted and enacted. This will take some time and in the meantime I am determined that the operation of the compensation tribunal will not be disrupted or delayed. It will continue to operate as normal under the direction of Mr. Justice Egan so that people who have already applied for a hearing will get that hearing as arranged. I will seek to ensure that everyone who has either gone through the tribunal, is currently before the tribunal or will be before the tribunal in the near future will retrospectively benefit from any changes made. It is also my intention that the terms of the compensation scheme should provide for an appeal to the High Court on the amount of awards made by the compensation tribunal.

Considerable attention has been given to the prohibition in the existing terms of reference of an award of aggravated or punitive damages. It has been pointed out that the option of awarding such damages is available to the High Court but not to the tribunal and that it would be preferable if it had the same freedom as the High Court in this regard. Accordingly, I will be proposing that this restrictive provision be removed from the terms of reference of the tribunal so that it will be free to award damages on exactly the same basis as the High Court. It will be for the tribunal to decide whether such damages are appropriate and how they should be measured if that question arises. In considering that question the compensation tribunal will be informed that the Government accepts the findings of the tribunal of inquiry and that the report's findings of fact should be accepted by the compensation tribunal.

Last Thursday I indicated the Government's intention to reappraise and amend the terms of reference of the compensation scheme following consultation with representative groups and the chairman of the compensation tribunal. I am hopeful that this consultation process can commence with the groups at an early date. I have also asked the BTSB to forthwith make known its position on liability on all outstanding cases in the light of the report's findings.

Regarding the National Drugs Advisory Board, the tribunal concluded that: “In the period 1975 to 1994, successive Minister for Health and the Department of Health failed adequately and appropriately to supervise the NDAB in the exercise of its functions concerning the licensing of the manufacture of products by the BTSB and the authorisation of products by the BTSB, in that they failed to provide to the NDAB the appropriate resources for carrying out those functions”.

The tribunal found that the levels of staff, [1171] particularly on the technical side including inspectors, was inadequate. Consequently, the NDAB did not carry out regular and adequate inspections of the BTSB. While the tribunal found that such inspections would not have revealed the particular batches which gave rise to the infection of anti-D except by some form of chance, it states that:

If those resources had been provided and if there had been appropriate inspections and investigations, it is possible that the reactions of the recipients of anti-D in the period 1976 and 1977 to the contaminated product, would have been revealed and that the persons involved in the BTSB would have made further investigations than they did if they were aware of the likelihood of further inspection and interrogation.

The position now is very different as a result of the steps which I have taken in the last two years. The NDAB has been replaced by the Irish Medicines Board, on foot of the Irish Medicines Board Act, 1995. All statutory licensing functions previously held by the Minister for Health have been transferred to it to eliminate the unnecessary additional layer of administrative process which contributed to the backlogs in the licensing system in the past.

A major management consultancy exercise was commissioned in 1995 to identify the staffing, systems and operational procedures which the new board would require to carry out its functions properly and the previous organisation has been restructured in line with the recommendations which emerged. In particular, the licensing fees charged to the industry have been set at a more appropriate level to ensure that the board has adequate resources to carry out its functions thoroughly, efficiently and without undue delay. The organisation is now driven by a streamlined board with a management rather than a technical orientation. It has also been relocated in new premises as those used by the NDAB were inadequate and a hindrance to increasing the efficiency of the organisation.

Since coming into office I have addressed and resolved the organisational and resourcing problems which the tribunal found to have beset the NDAB for the previous 20 years.

I now wish to turn to the supervision of the BTSB by the Department of Health since February 1994. Chapter 13 of the report of the tribunal deals with my response and that of my Department and the response of my predecessor, Deputy Howlin to the hepatitis C issue. This response included the establishment of many programmes and schemes to support the victims of this terrible tragedy and to alleviate as far as possible the human suffering occasioned by the hepatitis C infection of the anti-D product and the blood supply.

[1172] I wish to briefly outline the various programmes and schemes and the findings of the tribunal in relation to these. A national blood screening programme was announced by my predecessor, Deputy Howlin, on 21 February 1994 to screen all women who received the anti-D product in order to identify those who were infected with hepatitis C. For persons who were diagnosed positive for hepatitis C under the screening programme, acute hospital services were put in place in special units in six designated hospitals, namely, Beaumont, the Mater, St Vincent's and St James's in Dublin, Cork University Hospital and University Hospital, Galway. These services, provided under the Health Act, 1970, are free of charge and include access to both inpatient and out-patient treatment as required. Special funding has been and will continue to be provided by the Department of Health for these services. For example, in 1996 a special sum of £2 million was provided and a similar sum will be allocated for 1997. The Tribunal of Inquiry concluded that: “The overall picture appears to be that treatment as far as treatment has been developed by the medical profession in general for this unfortunate disease was adequately provided in these units”. The special secondary healthcare services are included in the healthcare package agreed with the groups representing persons with hepatitis C.

The Tribunal of Inquiry stated that the ex-gratia expenses scheme apparently worked “reasonably satisfactorily”. It concluded that it was satisfied that the decision of the then Minister for Health, Deputy Howlin, to set up an expert group was “an adequate and appropriate response to the problem of trying to find out what actually happened in regard to this infection of anti-D”.

It has been widely alleged that I engaged in a cover-up by failing to immediately set up a tribunal of inquiry in March 1996 when laboratory test request forms or quantitation reports indicating the clinical diagnosis of infective hepatitis discovered by the BTSB in the action being brought against them by the late Mrs. Brigid McCole became public. Both I and the Minister of State, Deputy O'Shea, informed the Dáil that these test request forms did not constitute any fundamental difference in the information available with regard to the wrongful use of patient X's plasma. It was claimed by some Senators that these quantitation reports were of fundamental importance and altered the entire situation concerning the events of 1976 and 1977.

The tribunal concluded that the quantitation information did “not constitute new, dominant or fundamental medical evidence” and did “not form a foundation for any particular conclusion which would not have been reached without them to the general wrong doing in the use of the plasma from patient X”. It further concludes that my decision not to set up a tribunal of inquiry at that time “was an adequate and appropriate reaction to the facts as they then were”.

[1173] In addition, the tribunal indicated that “the attitude taken by [myself] and Minister O'Shea, in reply to the Dáil questions in relation to this issue would appear to have been correct”. In all fairness, I would ask those Members of both Houses who laid those charges against me and the Minister of State, Deputy O'Shea to come forward and withdraw the charges.

The tribunal concluded that from the evidence of the communications between the Department and the BTSB with regard to the targeted look-back programme that, at all relevant times, it would appear to indicate an adequate and appropriate reaction.

I announced, on 12 September 1995, the national optional testing programme. This programme was introduced to ensure that all recipients of blood transfusions and blood products, who might have become infected with hepatitis C through the receipt of transfusions or blood products, were given the option of being tested free of charge.

The health care package agreed with the representative groups includes primary healthcare services as provided for in the Health (Amendment) Act 1996.

In respect of the health care package, the tribunal concludes that: “on balance the position would appear to the Tribunal to be that the Health Care Package, when finally provided, was appropriate and that it was, when provided, adequate but that some element, although not a great one, in the delay in bringing such a package into statutory from, was not an adequate response to the particular urgency which attached to that task”.

In relation to this conclusion, I would like to outline the timing of the various stages of the passage of the Bill in both Houses of the Oireachtas and the consultation and arrangements which took place for its implementation.

In November 1995 negotiations took place with Positive Action on the health care services and on 4 December 1995 the Government authorised the drafting of the Health (Amendment) Bill, 1995. On 11 December 1995, I sought Government approval for the text of the Bill and on the 12 December 1995 the Government approved its publication. The Second Stage debate on the Bill took place in the Dáil after the Christmas recess on 27 and 28 February 1996. During March and April, further negotiations with Positive Action and other representative groups on the amendments to the Bill took place. On 8 May 1996 the Committee Stage debate took place in the Select Committee on Social Affairs and Report and Final Stages were taken in the Dáil on 30 May 1996.

The Second Stage debate in this House took place on 13 June 1996 and the Committee and Final Stages were taken in this House on 20 June 1996. In July and August 1996 negotiations, including negotiations regarding fees, took place with professional organisations, particularly with GPs, and health boards on the implementation of [1174] the provisions of the Act. Consultations with the representative groups on the design of application form, health cards and arrangements for service delivery followed and on the 28 August 1996 I signed the commencement order bringing the Act into effect on 23 September 1996.

On 17 December 1996 I announced my intention to establish an optional HIV testing programme offering screening to blood transfusion and blood product recipients who may be at risk, however small that risk might be. Before commencing this programme, it is absolutely essential that the risk, if any, involved for recipients, according to the year that they received the transfusion or blood product and depending on the risk, if any, of particular products, must be determined, as far as possible so as to enable each recipient to make a fully informed decision, in consultation with his/her general practitioner in relation to availing of screening. I am hopeful, that the preparations for the optional HIV screening programme, which are well advanced, will be completed in the coming weeks. In the meantime, the HIV targeted lookback is continuing.

On the 28 January 1997 I announced the Government's intention to establish a tribunal of inquiry to examine specific urgent matters of public importance; (a) the HIV infection of blood and blood products manufactured and distributed by the BTSB, and (b) such further matters in respect of blood and blood products as may require investigation in the light of the report of the hepatitis C tribunal.

I stated that it would not be possible to submit the terms of reference to both Houses of the Oireachtas for approval until the report of the tribunal of inquiry had been submitted to me as it would not be possible to say what matters of urgent public importance would remain unaddressed. As Members are aware, the report was submitted to me on 6 March 1997 and the detailed terms of reference will be finalised, in consultation with the Irish Haemophilia Society, at an early date. The success of the hepatitis C Tribunal of Inquiry can, in part, be ascribed to its very specific terms of reference. Accordingly, great care will be taken to ensure that the terms of reference of this proposed tribunal will be very tightly framed to address specific issues.

As Members of the House know, the Government has agreed, at my request, to refer the report of the tribunal of inquiry to the DPP. This issue was argued before the tribunal of inquiry and the tribunal considered that it would not be appropriate for the tribunal to make such a referral. However, because of the enormity of the tragedy and the contents of the report, I have, with the authority of the Government, referred the report to the DPP.

All parties in this House, who have served in Government, must bear some responsibility for the events which have occurred. The tribunal comments adversely on the failure of successive Ministers for Health to adequately fund the NDAB between 1975 and 1994.

[1175] I am aware that no member of the Progressive Democrats has held office as Minister for Health. The Progressive Democrats, however, were in Government between 1989 and 1992, when some of the most shocking events occurred; the lack of action when the Middlesex letter clearly informed the BTSB that patient X had suffered from hepatitis C and the use of patient Y's plasma when she had tested positive are examples of this. They must also bear collective Cabinet responsibility for the inadequate funding of the NDAB during their period in office. They should also recall that two of their leading members were Cabinet Members in Fianna Fáil Governments from 1977 to 1981 when the original infection was occurring and spreading through many unsuspecting women. Spokespersons for the Opposition should remember this before they launch political attacks.

I welcome and invite contributions from all sides of the House regarding the management and delivery of the blood supply service. What I do not welcome are unfounded or ill-advised headline seeking or sweeping statements about matters requiring clear medical direction or medical expertise.

A number of persons asked why the conduct of the McCole case was not a matter into which the tribunal inquired. A tribunal of inquiry such as this is set up by the Houses of the Oireachtas. Our Constitution guarantees the separation of powers between the Houses of the Oireachtas and the courts. Consequently, it is not constitutionally possible for the Houses of the Oireachtas to initiate an inquiry into how a case was conducted before the courts. The Government has strong legal advice that the Oireachtas cannot attempt to deal with the issue of how a court case is handled or to make findings on the way it is handled. Any such issue is a matter for the courts themselves.

Once again the issue of the conduct of the McCole case has been raised. The position is as I have explained it on a number of occasions previously and as was explained by the Taoiseach on the order of business in the Dáil this morning. There were three defendants in the case in question: the Blood Transfusion Service Board, the National Drugs Advisory Board and the State. As far as the BTSB and the NDAB are concerned, they had separates boards, separate legal teams and separate insurance in regard to liability and pursued their own independent legal decisions and strategy on the basis of their advice and authority. State boards of all kinds daily take decisions on legal cases being taken against them which are not the subject of direction, authorisation or decision by Government. It would be impossible for the State board system to function in any useful way if the decisions about acceptance or otherwise of liability by a State board were to be referred to the Cabinet for decision. They were not referred to the Cabinet for decision in this matter.

[1176] As far as the State defence is concerned, the Government did receive formal legal advice that the State, as distinct from the BTSB, did not have a liability in this matter. That is obviously legal advice which, when received by any Government it must take due account of, particularly from the point of view of accountability for public funds. It is not possible for the Government to ignore legal advice about liability in regard to taxpayers' funds. When the advice was given as to the State's liability in this matter, that advice had to be taken seriously, as it was, in any discussions we had on this matter.

I hope Members will appreciate and understand, however, that the Government's priority was to set up a non-adversarial system for the quickest dispensement of compensation to the victims. We did not want to get involved, as a priority, in legal cases in an adversarial setting but rather to ensure, through the establishment of a non-adversarial tribunal for compensation, that compensation would be paid to the women as quickly as possible and, subsequently, to the other victims, both men and women. That was our priority. This problem existed for some time but the Government establishment of a tribunal of compensation ensured, without the requirement of being engaged in adversarial faultfinding, that there would be quick compensation for the victims. The issue of fault and liability is a separate matter. Our first priority was to ensure there would be a speedy and effective way of compensating the victims as their concerns come first.

I know that many Senators are anxious to contribute to this debate and that they will have many questions and comments about the report of the tribunal of inquiry and the BTSB. I welcome such comments and I will endeavour to answer the questions when I conclude this debate this afternoon.

Mr. Finneran: I thank and compliment former Chief Justice Finlay for producing the report on hepatitis C. His work was hamstrung in so far as the political accountability of Government was not an issue on which he could investigate or report. That was a major omission in the terms of reference of the tribunal.

There are many matters outstanding in this debacle. Political accountability has not been and is not being addressed even today. There has been no Government apology to the victims of the State's malpractice and the actions of the Government in the McCole case have not been explained adequately. Nobody who has read newspaper reports or this report could be satisfied that the State could involve itself in an attempt to blackmail the McCole family when Mrs. McCole was trying to establish her rights through the courts. That matter has not been resolved or addressed.

The hepatitis C scandal is the biggest health scandal in the history of this State. Over 1,000 women were infected by an agency of the State and, while fingers have been pointed at people [1177] who were responsible and who did not act properly, no blame has been accepted by those in charge politically. The fact is that many of those who were responsible for infecting over 1,000 women retired with golden handshakes. They left the service without being brought to book. I welcome the fact that the report of the tribunal has eventually been referred to the DPP. This was a matter of grave negligence over many years. I have been involved on many occasions in forcing the Government to address this situation properly.

Since we last debated this issue, a number of more disturbing situations have arisen, one of which relates to the actions of the former Minister for Health. A claim was made in the other House that he failed to bring this matter to the attention of his Cabinet colleagues. If that is the case, it is most serious. Indeed, the same Minister indicated yesterday on radio that the Cabinet had decided on certain matters; this constitutes new evidence.

The simple facts of the case are that the women who were infected by the State agency had to involve themselves in all kinds of activities to get their cases heard and have their rights acknowledged by the Houses of the Oireachtas. I remember the debate in which we sought Government agreement for a statutory tribunal and were voted down and an ad hoc tribunal was put in place. That has now taken a turn in so far as there is now provision for a statutory tribunal. I welcome its extended powers which are equivalent to those of a court. This is not before time.

There is still one major outstanding matter, and that is, how many more people have been infected with hepatitis C? Will the Minister provide a national screening scheme to establish the full extent of hepatitis C? That is now necessary to address this matter and bring it to a conclusion because many people who have not been contacted are worried that they are infected and they want the State to act on their behalf. The Minister should provide a national screening service to establish the extent of infection.

I join with the Minister in complimenting all those who have contributed to the blood supply over the years. I agree that Ireland is almost unique in that people give their blood voluntarily to help save lives. I join with the Minister in asking the people of Ireland to continue to give blood. To show their care for their fellow human beings, they should continue to provide a voluntary blood service.

The State has a responsibility to ensure that those who donate blood are fit to do so, that the blood is stored and made available to those who need it and that blood products provided by the State are safe because that was not the case in the past. Defective products were provided to Irish men and women who became infected and these people now have a disease for which there is no cure. Let this never happen again.

It is extraordinary that to date no person has been charged with an offence in relation to this [1178] major health scandal. The Minister has said that the Blood Transfusion Services Board, the National Drugs Advisory Board, the Department of Health and other agencies had independent responsibilities, independent legal teams and were like independent republics. There has been an attempt to create a barrier between the agencies, the Department and the Minister, but any such barrier is fictious. All those boards are there at the behest of the Minister if he wishes to intervene at any time. Under law the Minister for Health can intervene in any situation.

The Minister created this imaginary wall so that he does not have to accept the political responsibility for what happened. There may be others for all I know, including his predecessor, Deputy Howlin, but, given the information available to us, we have to deal with the present. That is too bad. At the end of the day the Minister has the responsibility. He should not spread the blame and distance himself from State negligence which concerns both the Minister and the Government. While the Minister wants to save himself politically, he is to some extent covering his own tracks by passing it on to the State agencies.

Mr. Doyle: That is very unfair.

Mr. Finneran: If the terms of reference given to Judge Finlay had included political responsibility, more might have been established. However, the report is restricted in so far as the terms of reference did not allow the judge to evaluate political accountability. If the Minister had nothing to hide, why were the terms of reference not broad enough to take political accountability into consideration?

The full truth of what happened has not yet been given and we may never get it because it is unlikely there will be any further inquiries. I do not believe, however, that the full truth regarding this matter has come out. It is highly unlikely that State boards and agencies could have acted thus over the past few years while the Government or the Attorney General stood that far back and did not get involved, take advice or acquaint themselves with what was happening. I find that hard to believe and I doubt if, in fact, that was the situation.

I appreciate what the Minister said in the House as a person but the facts are that even at this stage no apology has been made to those women on behalf of the State. The apology and liability issues have been pushed onto agencies and seem to have been kept at arm's length from the political head and the Government itself. I cannot but think that was done to save political skins.

In his speech the Minister spread it around, saying other Minister and different parties were involved over the years. This happened some time ago but it is important that matters should be dealt with when they come to light. Other than a statement made in Dáil regarding one former [1179] Minister, it has not been established that anybody had information and did not deal with it. To my knowledge that is the situation.

Mr. Magner: That is the old school of politics.

Mr. Finneran: I welcome the Minister's decision to set up a consumers' or users' committee. Increasingly, where State services are being provided we must have some kind of consumers' or users' council. I welcome that very good decision.

The BTSB is a necessary part of the health services. I hope public confidence in it will be restored so that people will continue to donate blood and use blood products.

Mr. Magner: And that is all our jobs.

Mr. Finneran: I fully appreciate we all have a responsibility in that matter.

Mr. Magner: Every one of us.

Mr. Finneran: I fully accept that as spokesperson on Health for my party I have a responsibility. I have no problem putting that on the record. If I do so, however, I must also say there is a responsibility on the Government and its agencies to ensure the things that happened in the past will not recur.

Mr. Magner: Absolutely.

Mr. Finneran: Information came out in the last couple of weeks that somebody who was infected had been asked to donate blood again. We needed that like a hole in the head. That type of activity lessens public confidence in the BTSB. The Minister said he does not accept that but the people who spoke up were right to ask for accountability in this matter. Irrespective of who is head of any board, they must take responsibility and must state that mistakes cannot and will not be made in matters of life and death. They have a responsibility to ensure——

Mr. Magner: People asked for the board to be scrapped.

Acting Chairman (Mr. Dardis): Senator Finneran without interruption, please.

Mr. Finneran: If any board is not in order, let it be scrapped. Boards have been scrapped before. I remember that the former Minister for Transport, Energy and Communications, Deputy Lowry, scrapped boards and, as far as most of the country was concerned, they were working quite well.

Mr. Magner: I am talking about blood, not CIÉ or Aer Lingus.

Mr. Finneran: Whether chief executive officers, directors general or chairpersons of any board are [1180] involved, if they have responsibility for something working in a certain way which is found to be flawed or defective, there is a responsibility on the Minister to say either you do the job or move aside and we will get somebody else to do it. As far as I know, what was said at that time was that if it was not working properly then the board or person should be removed. If it was not working properly and a genuine mistake had been addressed, well and good, but we must have confidence. That is important. Unless confidence is there, the public will not feel the State is providing a proper blood supply or blood product service.

I hope what the Minister has put in place will safeguard blood supplies to the public. I also hope that, as a priority, the Minister will introduce a national screening service for people who may be infected but who have not yet been identified.

Mr. Doyle: I thank Mr. Justice Finlay for his Report of the Tribunal of Inquiry into the Blood Transfusion Service Board, which is easy but sad to read. It is damning of the Blood Transfusion Service Board and of several key officials and it sets out a litany of mistakes made by the BTSB.

The primary cause of the infection of anti-D with hepatitis C was the use of plasma from patient X who underwent therapeutic plasma exchange treatment and developed jaundice and hepatitis C. The use of this plasma was in breach of the BTSB's own standards for donor selection which prohibited the use of blood or plasma from a person with a history of jaundice or hepatitis and from a person recently transfused.

It is clear from Mr. Justice Finlay's report that by the middle of December 1976 all senior medical staff at the BTSB were concerned about the plasma obtained from patient X. They were aware that hepatitis had been diagnosed and that this patient was suffering from jaundice. Unfortunately, however, they continued to manufacture the product. They also failed to recall the contaminated batches and to prevent the issue of further batches made from the plasma obtained from patient X.

It is clear from the report that the BTSB acted unethically in obtaining the use of plasma from a patient without seeking her consent. It is also clear that a further cause of the infection of anti-D with hepatitis C was the use of plasma from donor Y who was undergoing a course of therapeutic plasma exchange in 1989 and whose plasma was stored and then subsequently used in 1992, although the stored plasma had been tested for hepatitis C and four separate tests had proved positive. The BTSB's chief biochemist decided to use the plasma notwithstanding the result of at least one test which she was informed had proved positive.

The most damaging aspect of this saga was the BTSB's response to a letter from the Middlesex Hospital in 1991 concerning the infection of patient [1181] X's plasma with hepatitis C. Mr. Justice Finlay states in his report:

With regard to the position upon the receipt of the letter of the 16th December 1991 from the Middlesex Hospital, the reaction of Dr. Walsh, and to a lesser extent of Mrs. Cunningham, to that letter can only be construed as a blank refusal even to contemplate the consequences of what had been done in 1977 and a vague hope that by ignoring the problem it would go away.

This was a dereliction of duty which was compounded by the fact that the BTSB failed to inform the women who had or might have been infected in 1991 after the letter from the Middlesex Hospital had been received or to inform the Department of Health or the National Drugs Advisory Board of that infection. The officials in the Blood Transfusion Service Board were not prepared to face up to the consequences of the wrong committed in 1977.

Much has been written and said about ministerial responsibility and many allegations have been made against the Minister for Health, which Mr. Justice Finlay found unjustified. In 1989 I moved a Private Members' motion in this House seeking compensation for haemophiliacs who were suffering from AIDS as a result of infected factor VIII. I did not condemn the then Minister for Health or ask him to accept responsibility. I attended meetings where the number of AIDS patients was written on the wall but this number decreased each week as patients died. It was a moving experience to deal with these people who just wanted compensation. The Minister for Health at the time, who was a member of Senator Finneran's party, said the State would not pay compensation. I told him that another Minister for Health would because these people had good cases. A Private Members' motion was also defeated in the other House which caused a general election. This is not the first tragedy as a result of infected blood, but this Minister has dealt more humanely with it than a previous Minister for Health.

It is also wrong for politicians to try to rewrite sections of a report, such as this one, because its findings are unacceptable to their political views. If a tribunal is set up and publishes its report, it should be accepted by every Member of the Oireachtas.

Many charges have been made against the Minister for Health and the Minister of State at the Department of Health. When documents were discovered in 1996 in relation to the McCole case which referred to the original donor of the infected blood, the Minister was accused of engaging in a cover up by failing to establish a tribunal of inquiry in March 1996. The Minister of State at the Department of Health, Deputy O'Shea, was also accused of deliberately misleading the Dáil by not divulging this information. However, Mr. Justice Finlay came to the conclusion [1182] that the discovered documents did not constitute new fundamental medical evidence.

Another allegation made against the Minister for Health was that he published the report of the expert group chaired by Dr. Miriam Hederman-O'Brien knowing it was inadequate because it did not deal with the failure to grant a manufacturer's licence under the Therapeutic Substance Act, 1932. However, Justice Finlay disagreed with this allegation. He also supported the decision by the Minister for Health to establish a compensation tribunal for the victims of hepatitis C. The Minister for Health was also vindicated in terms of the timing of the change of personnel in charge of the Blood Transfusion Service Board and the health care package provided for the victims. Mr. Justice Finlay said he was disappointed it took so long to get the legislation through the Houses. He might not have made that remark had he known the difficulties involved in getting it passed.

The Department of Health has played an important role in this sad episode. Ministers for Health come and go but the Department is a permanent arm of the State which is responsible for protecting the health of the citizens. However, in this instance the Department of Health failed to fulfil its responsibility. Mr. Justice Finlay states in his report that in the period 1975-94 successive Ministers for Health and the Department of Health failed to supervise the National Drugs Advisory Board in the exercise of its functions in relation to the licensing of the manufacture of products by the BTSB and that it failed to provide the National Drugs Advisory Board with the appropriate resources to carry out these functions. He further states that if those resources had been provided and appropriate inspections and investigations carried out, the reactions of those who received anti-D between 1976-7 would have been relieved and the persons involved in the BTSB would have been made more aware of their roles and responsibilities.

The report is also critical of the Department of Health which delayed introducing the hepatitis C screening test at the beginning of 1991 when its reliability and safety appeared to have been universally established. The Department of Health eventually introduced a screening test in October 1991. However, it was probable that a number of people were infected in the period of the delay in the introduction of this test. The tribunal held the view that the chief medical officer at the Department of Health had to bear responsibility for the delay. However, the export group report revealed that when the chief medical officer finally agreed to the introduction of the test in May 1991 the BTSB was not informed of the decision for several months. It was also not informed that officials from the Department had set aside funding for such a screening test. Almost a year was lost haggling before the screening test was introduced. The administrative side of the Department must bear major responsibility for the delay, which appeared to have been unnecessary and unwise having regard to the safety advantages of [1183] introducing hepatitis C screening between the earlier part of 1991 and October 1991.

From June 1994 Positive Action, on behalf of its members, was making it clear to the Department and the BTSB its objections to the counselling of women. Mr. Justice Finlay was of the opinion, in regard to the counselling of victims of hepatitis C, that the solution eventually achieved in 1995 was appropriate; but having regard to the importance of the element of the treatment of victims, the reaction of the Department earlier in 1994 in failing to insist upon a more rapid putting in place of an independent council was inadequate.

Chapter five of the report was one of the most harrowing, where Mr. Justice Finlay outlined the consequences of the infection of anti-D. Our sincere sympathy must go to anyone who has been infected with this terrible problem. I concur with the sentiments of the motion before the House which acknowledges the extraordinary anguish and distress experienced by the victims and their families and acknowledges the widespread sense of public outrage at the matters disclosed in the report. The House supports the Government's intentions to amend the scheme of compensation and its terms of reference and that the tribunal should be established on a statutory basis. The Government has undertaken that it will not repudiate any of the findings of fact of the report of the tribunal into the BTSB in any proceedings either in court or before the Compensation Tribunal.

I am pleased to note the Government has decided to grant additional special damages to 1,600 victims of hepatitis C in recognition of the extraordinary anguish and distress experienced by the victims and their families. It is very important that we have confidence in the BTSB and in the blood supply. In order to sustain the confidence of the public in the BTSB and in the blood supply, certain steps have been taken by the Minister to ensure the organisation and running of the BTSB would be such that it will be recognised by those dealing with it as having effective and safe controls. Unfortunately, there has been severe criticism recently of the BTSB, including an error made by an official which could amount to the public losing confidence in our blood transfusion service. Such comments made by public representatives are totally irresponsible.

Even though the report sets out the defects of the BTSB and the mistakes it has committed in the past, nevertheless it has to be recognised that it has supplied, with the exception of anti-D and factor VIII products, a safe supply of blood to our hospitals over a long number of years. This is due mainly to the generosity of the people who give donations. Many people who have had operations and or have been in accidents depended solely for their survival on the blood supplied by the board. They are alive and well and that must be taken into account to bring balance to the issue.

[1184] It is a sad saga, but the Minister, Government and Department of Health have dealt as sympathetically as possible with this terrible problem. I am grateful the Minister accepts the majority of the recommendations of the Finlay report.

Dr. Henry: Paragraph (d) of the motion states that Seanad Éireann “notes and acknowledges the widespread sense of public outrage at the matters disclosed by the report.” Public outrage is even less than that felt by the medical profession, along with a sense of betrayal, because we put such confidence in the BTSB, which had constantly assured us of its high standards. Paragraph (e) states that “we fully understand the extraordinary anguish and distress experienced by the victims and their families”. This is seen on a day to day basis by members of the medical profession and I hope we will be forgiven for any inadequacies or perceived inadequacies in our dealing with these patients. I apologise to anyone infected who feels I have not done enough to help them.

Therapeutic misadventure on such a scale has mercifully never happened before in this country, but hepatitis C is an international problem and similar disasters have unfortunately happened elsewhere. Whenever I have spoken on this topic, I stressed that anything we can do to help those infected must be done; but we must also ensure, in so far as we can, such an occurrence does not happen again and that we learn from the mistakes made here and internationally. I will do anything I can to deal with those infected. I went to the first meeting of Positive Action and made that promise; but after attending two other meetings I had to draw back, because as Jane O'Brien, who had so skilfully organised Positive Action, said, my role as a doctor and a politician were becoming somewhat confused. Naturally, not being an expert in transfusion medicine or hepatology, I did not feel my advice as a doctor was the best those patients could get.

I congratulate Positive Action on its role in this sorry saga and the responsible way in which it has handled publicity. It is essential from the point of view of those infected that the group should continue to receive support because its help will be needed by all of us for some time. It was also important in helping those who had to deal with victims to understand the situation. The expert group report went a long way in explaining the disaster; but, while I do not wish to accuse anyone of mendacity, some people appeared to have been economical with the truth, to quote a famous British civil servant. What a pity a subpoena was required to get the most essential medical practitioner to give evidence about what happened in 1977. The saga around patient X is almost unbelievable. So many international transfusion rules, as well as their own regulations, were broken by those working in Pelican House. The doctors involved knew she had infective hepatitis. It was the only possible diagnosis, but they had to decide between hepatitis A, hepatitis B and [1185] what was then known as hepatitis non-A or non-B, and once a negative result was given for hepatitis B, they decided she had hepatitis A. However, even giving that blood was incredibly irresponsible because, as I pointed out in a debate when quoting from a copy of Muir's Pathology written around that time, undergraduates were able to see that it was possible for hepatitis A to be transmitted by blood. It was a most extraordinary decision and the unfortunate people who were infected have had to live with it since.

In regard to the excellent reporting by the general practitioners whose patients became jaundiced and their questioning of the association with anti-D, what happened smacks of the experts telling the underlings not to question their betters. I applaud these people who did their utmost to try to get the BTSB to take some notice of the fact there was a connection between anti-D being given in maternity hospitals in Dublin. It was an appalling example of not taking notice of those working at the coal face. Much emphasis has been placed on the finding of forms with infective hepatitis written on them. As the Finlay report says, the expert group's report would not have been changed by knowing these papers existed because it was obvious they existed at some stage. The amount of documentation regarding donor Y not shown to the group was incredible. It was impossible to work out what happened regarding donor Y. This was in the recent past. By 1989 much more was known about hepatitis C. Yet plasma was taken once again from a patient who was undergoing plasmapheresis. It is an international rule that blood for blood products should never be taken from such a patient.

By 1989 the presence of unidentified viruses was also known and hepatitis C had been identified, but we had no reliable test. This plasma was stored and used in 1992 when tests for hepatitis C were available and the plasma had tested positive four times. The BTSB was also aware there were some deficiencies in its production of anti-D because it was trying to introduce a solvent detergent stage in the process. It had been pressing for this possibility in 1990 and 1991 and had investigated the possibility in New York; yet it went ahead with this stage of the process without clearance that the patient had been retested and clear of infection. It kept using this anti-D until 1995 when testing was widely available for hepatitis C.

The report states on page 148, paragraph 10, that the main reasons why these wrongful acts were committed were:

An undue emphasis on the necessity to use plasma from therapeutic plasma exchange patients so as to maintain the supply of plasma for the making of anti-D; an undue and unsupported belief in the probability that the method of production of anti-D would inactivate any virus that existed; and a reluctance to admit the possibility of having been wrong and the possibility [1186] of a failure of the production of anti-D which would be involved in the recall of the product.

That is a shocking paragraph.

The report further states on page 154, paragraph 5:

The documentation concerning the plasma from Donor Y was not available to the expert group, and had it been so they would have been in a position to make a decision which they were not in a position to make, that the infection arising from that was something that should have been avoided and was due to wrongful practices on the part of the BTSB.

This is most serious because at that stage the BTSB knew its manufacturing process was inadequate because it was trying to introduce another stage. It also knew the product could be tested.

I will pass over my own problem, where I was given the impression by the BTSB that the new imported anti-D was FDA approved, except to say I have rarely been so shocked as I was in Washington when I was told the truth by the haematology section of the FDA. When Miss Moran was giving evidence to the tribunal she was right in saying she thought a telephone call from me to give this information preceded my letter to the Minister. It is interesting to note that on the day I telephoned Ireland with this good news, going straight from the FDA to the Irish Embassy to make the calls, the Blood Bank wrote to the Minister to say FDA approval was actually only pending. I am sure that was just a coincidence.

There is, of course, political accountability in this sad history. I hope anything I say will not be considered to be party political because all the Ministers for Health I have known have been most honourable people. However, page 151 of the report states:

In the period 1975 to 1994, successive Ministers for Health and the Department of Health failed adequately and appropriately to supervise the NDAB in the exercise of its functions concerning the licensing of the manufacture of products by the BTSB and the authorisation of products by the BTSB, in that they failed to provide to the NDAB the appropriate resources for carrying out those functions.

I used to go to the old NDAB when it was at the top of Harcourt Street The situation then was dire enough. I hope any solicitor present will excuse me for saying it looked like the crazy solicitors' offices one sees in films with boxes of paper and files everywhere. I also went to its new headquarters in Adelaide Road. That place was an incredible fire hazard because there were even files on both sides of the stairs one had to climb to see Dr. Scott. Mr. Justice Finlay was right to say, when told that she used to work 18 hours a day and did not take her annual leave for 18 years, that that should be a terrible warning to us not to do the same.

[1187] I wonder if any Minister for Health ever went there, apart from opening the premises, to see what was happening. Did they realise it was impossible to police the pharmaceutical industry or examine new products with the resources which were given to that unit? The underfunding of that unit was an incredible indictment, which, as far as I know, successive Ministers were constantly told about.

As one who used the products passed by the NDAB, this chapter makes chilling reading. It is very sad to see these one page reports. I have not heard of any legislation regarding this being passed by the Oireachtas. The Department of Health cannot pretend it was unaware of the problems and worries in the BTSB because it contacted the Department on two noteworthy occasions, first, in regard to ALT testing and, second, regarding the introduction of testing for hepatitis C.

In 1989 there was a general international appreciation that non A and non B was a serious post transfusion hepatitis risk. A non specific test, ALT, alamnie amnotransference, was used in some European countries and in the United States to screen blood. It was reckoned a 40 per cent reduction in the transmission of non-A/non-B hepatitis was achieved in the US, with similar results in other countries.

In Canada, a group in McMaster University initiated a research programme with the Canadian Red Cross, the liver study units in Mount Sinai Hospital and the University of Manitoba. One group of patients was given blood which was ALT tested and the other non-ALT tested blood. Canada was not generally screening blood with the ALT test at that time. It reduced the post-transfusion rate by 40 per cent; but when these patients were subsequently tested when hepatitis C testing became available it was found that the hepatitis C infection rate had been reduced by 70 per cent. Mr. Justice Finlay did not feel the Department of Health had been remiss in failing to introduce ALT testing, but I wonder if he had access to the article on this in The Lancet, 1995, section 345, pages 21-25.

The BTSB wrote many times to the Department regarding ALT testing and was supported by leading haematologists from three of Dublin's major haematology departments. However, it appears home grown advice does not carry much weight in the Department of Health.

From December 1989 the BTSB sought leave to introduce hepatitis C testing. In February 1990 it tried again. The then chief medical officer seems to have been aware of the importance of this but over the year came to the decision that screening in the Republic should not be introduced until it was introduced in the UK. When that CMO, Dr. Alfie Walsh, left office in August 1990 the new CMO, Dr. Niall Tierney, appears to have decided this was the right thing to do. Everywhere in Europe had introduced testing by the end of 1990 except the UK and Ireland.

[1188] There was then a most extraordinary development. The CMO received a letter from the Department of Health in the UK saying it was further delaying testing because of the Gulf War, so we delayed testing too. How high up in the Department of Health was our reason for delaying testing known? Did the then Secretary or the then Minister know? Both are very sensible and responsible men and I would find it hard to believe they would agree to such a plan of action, or rather inaction. If such a situation arose again would such a serious decision be made without ministerial consultation? This could happen to any Minister, so it needs to be explained.

Many cases could have been avoided if screening had been brought in then. An independent haematologist consultant in the UK, whom I contacted when I was trying to find out if there was any significance in the late introduction of testing, told me it was reckoned 3,000 cases of hepatitis C infection occurred in the UK because of late testing. We can expect the same proportion of patients here, relative to our population.

There are probably many cases of which we do not yet know. It is very important to remember this blood was not just given to old people with serious illnesses — it is well known that about 50 per cent of people die within two years of receiving a blood transfusion, which is nothing to do with the transfusion — but also to babies and children. It is impossible to say how important infections from hepatitis C at that time were in the deaths of ill people who were given infected transfusion.

If in that period, 1989-91, we had not blindly followed what was happening in the UK we may have been in a better position. Reading papers from the Department of Health there appears to have been an enormous reliance on what was happening in the UK, although we seceded from the UK a long time ago. While the UK is closest to us geographically, it would be an idea to look at the smaller Nordic countries when addressing health matters. They now have the lowest incidence of hepatitis C in Europe.

At the time in question, the BTSB appears to have been woefully understaffed at the higher level. There was only one haematologist. Not only was this a stand alone unit, which is always dangerous because the staff can become isolated, it was being run by one person. Efforts were made to recruit further staff but this was impossible because of the public service cutbacks. We must be much more careful not to apply such a blunt instrument to future cutbacks because it allows these situations to arise.

Dr. Emer Lawlor was not even confirmed in a permanent position. Furthermore, she had not been appointed to deal with transfusion medicine but to establish a bone marrow register to improve the treatment of leukaemic patients. We were also trying to deal with an increasingly complex and expanding transplant situation. These problems were not addressed by the Department of Health. In addition, the HIV disaster [1189] exploded. Indeed, at the time, juniors were not even sent to the Department on an emergency basis.

In view of this, we must consider the extraordinary lack of personnel who could have been useful at that time. Again, Mrs. Cunningham is described as the chief biochemist. Over how many was she chief? There was a terrible shortage of biochemists at that time.

We must address the fact that, at present, there are only 11 haematologists in the country while it is reckoned that approximately 28 are required for the proper, modern medical staffing of haematology departments. For example, Dr. Power is still working alone in Cork. Surely something could be done to appoint a second person there on an emergency basis?

When the disaster hit, both the BTSB and the Department were reluctant to face the facts. Dr. Boothman was the Minister's appointee on the board, but she said her role was to give the benefit of her expertise to the board, not to report back to the Minister about problems. However, she appeared to modify this approach in February 1994. Could the Minister clarify what his appointees to boards are supposed to do? Are they supposed to report back to him?

The Department of Health was again less than helpful when the hepatologists complained that the BTSB was not referring women they considered should have been referred. It appears senseless for the Department to have sent this letter to the BTSB. Surely it should have taken a more active role in disputes such as this, especially when the crisis was so serious? The Department also advised against sending to GPs the letter Dr. Emer Lawlor and Dr. Joan Power wanted to send alerting them to the fact that there had been a second period of contamination from 1992. Certainly, most of the emphasis in the campaign appeared to be on 1977.

No money ever repays a person for lost health. However, let us hope that the money given at the compensation tribunal will at least make it possible for those infected to lead a more comfortable life. Their medical care appears to have been properly organised. Patients should be told to try not to look on the worst case scenarios because that will not happen to everyone, please God. They should also be told that improvements in treatment are not impossible, indeed they are being discovered all the time. Looking, as a doctor, at the people involved I say there but for the grace of God go I, and I am sure that the remorse expressed by those involved is real.

I am glad the Minister has established a tribunal to deal with the problems faced by haemophiliacs regarding hepatitis C and HIV. It should meet as soon as possible. Similarly, the recommendations of the Finlay report, which have been accepted, should be speedily implemented. The first and most important step is to rapidly appoint more haematologists because it will take some time to get the BTSB onto a green site. The transfusion service and use of blood products can [1190] never be totally risk free, but we must learn from the terrible mistakes which made in these two dreadful episodes which have led to so many people being infected by anti-D, through transfusions and other blood products.

Mr. Magner: I compliment Senator Doyle on a thoughtful speech. I will prioritise my remarks under the headings of victims, blood supply, political responsibility and political reputations.

The Minister eloquently expressed his sorrow and heartache at the damage inflicted on these 1,600 women. He apologised on behalf of all in this House. The chilling account in the Finlay report of what happened to those women makes salutary reading because it links together the responsibility of an agency, a Department and political responsibility. We do not have a good record for accepting responsibility in some of these areas, and sometimes in all three. That has been the history of the State. No amount of money can compensate for what has happened to these women, but it is one way of expressing regret. They were the victims in this saga.

We have an immediate responsibility to protect the blood supply. Whatever about sacking the board, it is not possible to close down the BTSB and the operation of supplying blood products. These products are vital to the survival of men, women and children and any comments about the BTSB must be made against that background. This does not avoid responsibility nor does it evade establishing proper mechanisms and procedures to ensure that the blood products supplied by the BTSB are the best in the world. To that end, the chief executive of the BTSB, Liam Dunbar, has a primary reputation in his field. It is accepted by most people that he is the best person to hold that position. Likewise, the chairman of the BTSB, Joe Holloway is respected on all sides as a senior civil servant who held responsibility as Secretary of a Department for many years.

Human error cannot be excluded. Measures can be put in place to prevent that through a series of checks and balances. It is most important Members ensure that confidence in the blood supply is maintained. As Mr. Liam Dunbar said recently, millions of units have been supplied over the past two years, saving lives in every accident and emergency department of every hospital in the country, without any mishaps. He also stated that he believes our blood supply system is one of the best in Europe, if not the world. The type of confidence which is required should be expressed by all speakers.

The issue of political responsibility has occupied the other House, various radio stations and newspapers. It has been the subject of ministerial and Opposition statements. The resignation of Deputy Geoghegan-Quinn as the Fianna Fáil spokesperson on Health and the emergence of Deputy Cowen as the new spokesperson brought the debate to a new low level. He insulted in a most wounding way all the victims of this scandal [1191] when he linked it to the collapse of the Fianna Fáil/Labour Government in 1994. I will deal with the Deputy Cowen school of politics in the context of the role of the current Minister for Health, Deputy Noonan, and the former Minister for Health, Deputy Howlin.

In relation to Deputy Noonan, if I had to entrust an office of State to a particular person from any party, he would occupy a top spot. He has proved himself one of the most effective Ministers in this and previous Governments. I suspect the Deputy Cowen school of politics has never forgiven Deputy Noonan for taking over the Department of Justice and exposing the malpractices and politicisation of that office in a most disgraceful fashion by the previous Fianna Fáil office holder. The Minister has never been forgiven for that; as far as Deputy Cowen is concerned, that is his crime.

Deputy Cowen made personal, bitter and divisive allegations against Deputy Howlin. He claimed he was ashamed to share a Cabinet table with him. However, Deputy Cowen was not ashamed when it emerged that he had shares in a mining company while he was the Minister for Transport, Energy and Communications. He was not ashamed to allow Deputy Howlin defend him; Deputy Howlin took the view that no personal responsibility should be attached to the then Minister, Deputy Cowen. However, Deputy Cowen, with the accumulated bile of 1994, could not wait. He made a number of false allegations and brought this debate to a new low.

He was joined in that endeavour in the Dáil today by Deputy McDaid, who said: “Is it logical for Ministers to claim in post-tribunal interviews that they have been exonerated when the tribunal has been fixed in such a way....” Is Deputy McDaid suggesting that one of the most respected members of the Judiciary would accept a mandate from a Government knowing a tribunal was fixed? Is that Fianna Fáil's position at this stage? If so, it is not election fever but politics at its lowest and most base.

I am proud to have many friends in the Fianna Fáil Party with whom I shared office in the previous Government. In the main we did a good job together and I have no hesitation in saying that I would include many Fianna Fáil people on my list of those who are fit in every way to hold the highest offices in the State. However, the performance of some Members, particularly Deputy Cowen recently, leads me to believe that he, had not Deputy Noonan or Deputy Howlin, is unfit for office.

During the debate in the other House, Deputy Cowen dropped a few octaves and made a number of allegations with which the tribunal dealt. The actions of few Members have been put under such a clear and well defined microscope as the Finlay tribunal and the many senior counsel who posed questions. The tribunal exonerated the Ministers with regard to some of the charges [1192] made by spokespersons on the other side, specifically Deputy Cowen.

An Leas-Chathaoirleach: I am advised that Members of the other House should not be commented on and that personal references should not be made.

Mr. Magner: I can find another name for him and I am happy to use it if that is in order. My colleague, the current Minister for the Environment, Deputy Howlin, was judged under a number of headings. The first was ensuring that no further infection occurred on his watch. The finding of the tribunal was that from the day Deputy Howlin was informed of the infection of anti-D, nobody has been infected with hepatitis C from anti-D. Another issue was the question of ensuring that a replacement product free from infection was immediately available. The tribunal found that, on Deputy Howlin's instructions, a Canadian blood product was specially flown in within 24 hours and circulated to every hospital and accident and emergency centre in this country.

In relation to the question of finding out who was already infected with hepatitis C, the tribunal found that within three days of finding out about the infection, a major national screening programme was put in place. By the end of the year the programme had screened 56,000 women. Deputy Howlin was criticised for allowing the BTSB to carry out the screening programme. However, Judge Finlay found the only organisation with the expertise to carry out such a procedure was the BTSB. The other side did not suggest who should have carried it out in the absence of the BTSB. That was overlooked because the political points were much more important than trying to determine the truth or accepting the truth as determined by the Finlay Tribunal.

The maintenance of confidence in the BTSB and the blood supply was a responsibility of the then Minister, Deputy Howlin. The tribunal found that he established the expert group to examine the operation of the BTSB and sent it to outside experts to supervise the operation of the board. The arrangement of treatment, counselling and help for the victims was another responsibility of the then Minister, Deputy Howlin. Apart from criticising the delay in putting independent counselling in place — criticism which Deputy Howlin accepted and he apologised for the delay — the Finlay report found that treatment facilities, arrangements for ex gratia payments and arrangements for the help provided to the victims was adequate.

The issue of the cause of the infection was another responsibility of the then Minister. The tribunal found that the setting up of the expert group within two weeks of the discovery of the infection was the proper procedure to adopt at that time. Having reviewed dozens of different actions by the Minister, Judge Finlay found Deputy Howlin's handling of the crisis inadequate [1193] on three points, which have already been acknowledged by the Deputy. The political charges laid by the Fianna Fáil spokesperson on Health in the other House have insulted the dignity of the women concerned and done nothing whatsoever to assist in ensuring that procedures in the future and accountability in the past were the focus of the debate. Two Ministers have been subjected to an unprecedented examination and review of every decision they took between 1994 and 1996.

Senator Henry quoted page 151 of the tribunal report which relates to the period from 1975 to 1994. On this occasion I will not name names. I have no intention of trying to throw a cloak over every Minister for Health since 1975. It would not assist the situation because every holder of that office exercised due diligence in so far as their responsibilities were concerned. In their hearts, Fianna Fáil and the Progressive Democrats are well aware that Deputies Noonan and Howlin are, without taking away from other past and present officeholders, probably two of the most competent people to hold office in the State. However, this is an election year and that is why the debate has sunk to a new low in Irish politics.

The reality in dealing with a matter such as the hepatitis C crisis is that it behoves us to raise the standard of what we say and to try to address what has been the biggest health scandal in this State. We all share the responsibility collectively. The behaviour of the Fianna Fáil spokesperson on Health in the Dáil has led me and many others to the conclusion I reached this afternoon when I spoke to a very respected political columnist. He said that the only rationale for the irrationality of Deputy Cowen's attack on Deputy Howlin is that he has never forgiven him for the fall of the Government in 1994. Deputy Cowen's argument was graphically illustrated when he broke down on television after that Government's collapse. That bile was a long time coming. He has done himself, his party and the women of Ireland no service by making this the lowest political debate in recent times.

Mr. Roche: Pre-election frenzy can explain many things but not the preceding contribution. I found it absolutely astonishing, because I have the utmost respect for Senator Magner. He sits in the same ranks as a leader who over the years elevated personal abuse and vituperative and slanderous allegations to an art form. I was in the Dáil when politicians who are not above blame were regularly referred to by Senator Magner's party leader as the cancer in Irish politics, among other things. It is difficult to keep my peace while Senator Magner complains about people treating his party to the same coin.

I agree with many of Senator Magner's comments. This is the worst health scandal the State has ever seen. In France, those responsible for that country's blood scandal went to jail. Whatever happens here and however deserving the culprits may be, they will not spend any time cooling [1194] their heels where they rightly deserve to be. We will get involved in internal political savaging and not try to learn about the problems. The problems illustrated in this case are a combination of political incompetence and maladministration of the most criminal type. That is what we should be discussing.

This scandal is rightly described as the worst debacle in the history of the State. It has been made much worse by the manner of its handling by those with political responsibility for dealing with it. I do not know by what standard one judges a Minister — and the current Minister for Health is a competent, extraordinarily intelligent and adroit man — but I remember his reprehensible lapse in the Dáil, which was a backward hand to the women affected by this and to their families. That does not suggest compassion to me, but arrogance and an unwillingness to apologise until one is put to the wall.

Openness, honesty or compassion were singularly lacking in the manner in which this scandal was handled in its earliest days. Instead of those qualities, this Government responded initially with secrecy, mendacity of the most despicable order and a lack of compassion that could only be described as breathtaking. The instance in the Dáil, when the Minister insulted every woman infected by this horrific disease, was just an example of a breathtaking lack of compassion. To then suggest that the rhetorical excesses pursued by the Fianna Fáil spokesperson on Health can somehow be regarded as blame in this issue is nonsense. We should be discussing the issue before us and not the rhetoric in another House.

Ministerial energy and administrative ingenuity have not been used to seek a remedy for the great ill in this case. They have been used to seek scapegoats, as we have seen just now. A search for scapegoats and excuses is all we have as a response from the current Government to this crisis. We saw it in the Minister's contribution, and, regrettably, in my friend Senator Magner's contribution. I regard him as a friend and not just as a competent politician but as a politician who normally looks at the issue. He normally addresses the ball rather than the player, but on this occasion we must be very close to an election because everybody has lost their senses.

The extraordinary culpability in this matter was graphically illustrated when the Minister, Deputy Howlin's professional spin doctor, who is a GP, was caught by the media whispering into his State funded cellphone to tell Deputy Howlin that he had not been hung out to dry by an honest and decent civil servant who had given his views to Mr. Justice Finlay. That says everything, because all that mattered to Deputy Howlin or his private Svengali was not the horror that faced us; the real concern to the Minister and his Svengali was his political reputation and saving face. It was an almost Chinese fixation among Ministers.

The cost of State failures and destroyed private lives did not feature in that discussion. Yesterday on “Liveline”, the Minister, Deputy Howlin, let [1195] the cat out of the bag on one issue. It is the matter of the way the State, as a corporate entity rather than through one Minister, has responded collectively to this matter. Deputy Howlin, in a moment of uncharacteristic candour, raised the most serious questions about the State's response to this scandal. The position he and his colleagues have adopted on this issue is totally untenable and wrong. To go further, it is at variance with the truth for a Minister to suggest that the strategy adopted by the BTSB in court actions, and particularly in the McCole case, had nothing to do with the State. It went far beyond executive responsibility. That strategy was hatched at the top and Deputy Howlin made that very clear on “Liveline” yesterday.

In the interview, he disclosed, in relation to the despicable conduct of the State in the handling of the McCole case, that the legal strategy was decided by Government but earlier the Minister for Health stated that it was decided by some nameless individual in the BTSB. However, the Minister for the Environment admitted that it was decided by the Government. I do not know how this happened. While I differ with the respective Ministers, Deputies Howlin and Noonan, I do not suggest that they lack humanity. I cannot understand what collective madness marched the State down this particular route. Following the initial coverup, scandal and breakdown, the matter which must be subject to the most rigorous condemnation is the way the State decided to handle this issue. Yesterday the Minister for the Environment, Deputy Howlin, stated that the legal strategy was decided by Government. When asked if he took the decision, he stated that he did not because the Government makes the decisions as to how these things happen.

We are discussing this Government, not one of its predecessors or the current Fianna Fáil spokesperson on Health and whether he is a good or bad orator or was upset by what occurred in 1994. Everyone was upset by events in 1994. The issue at stake is the way the State decided to respond to this case. I cannot understand the lack of compassion displayed by certain people. How could Ministers of any political persuasion decide to handle the McCole case in the way it was handled, knowing what they knew? In his radio interview the Minister for the Environment admitted that he accepts this did not suit the McCole family and they were correct to take the route they did. That must be the understatement of the year.

The interview in question did not include an apology and while one was made today by the Minister for Health it is somewhat late. The Minister for the Environment's radio interview explains why the fifth issue in the McCole case was excluded from the terms of reference of the hepatitis C tribunal. The previous speaker referred to comments made by Deputy McDaid in the Dáil. Deputy McDaid inquired why the [1196] fifth issue raised in the McCole case was excluded from the tribunal's terms of reference and why were the other four issues were included. The only honest conclusion I can reach is that it was not politically expedient for that matter to be the subject of Mr. Justice Finlay's forensic examination. In that context, it must be clearly stated that the Finlay report is excellent.

In the Minister for the Environment's contribution yesterday, we have been given the first public admission by any Minister that the Government was collectively responsible for the strategy adopted in the McCole case. This admission is a damning indictment of the Government from the Taoiseach and Tánaiste down. To his discredit, he must have known that the cat was out of the bag and the Minister for Health tried to maintain the fiction that the Government was not involved in forming the legal strategy which was so insensitively pursued against a defenceless and dying woman. In the most recent Dáil debates and during his earlier contribution in this House, the Minister tried to shift responsibility for the debacle to the shoulders of others.

The decision regarding the handling of the McCole case was a political one. There is no gainsaying that. We suspected this from the outset but the proof was provided yesterday by the Minister for the Environment, Deputy Howlin. It is my view that if said Minister is the compassionate and caring person Senator Magner suggests, he would consider packing his bags and leaving office because he was Minister for Health at the time these events occurred.

The reality is that the entire political debate on this issue is merely heated rhetoric and will do nothing for the lives of the 1,600 people infected with hepatitis C. Money alone will not address the great injustice visited upon them but, as Senator Henry stated, it will help make their lives more comfortable. The greatest debt we owe those 1,600 people and ourselves is the truth.

We must understand where the breakdowns occurred in addition to coming to terms with the pathological obsession in Irish public life to defend one's back and the corrosiveness of official secrecy. Someone in the Department of Health was aware of what was taking place during the period in question. There must be something fundamentally wrong with the way the State is governed that so many Ministers, all of whom are good and decent people, could have been kept so abusively in the dark. When one reads the report there is a nagging doubt about the respect some public service bodies have for democracy and the people. The staff of such bodies are not invaders from another planet. Those who are responsible for this matter and who knew that what they were doing was wrong are Irish public servants in whom a major amount of trust was invested. We trusted them with the lives of the people. At the outset I stated that in a similar scandal in France, the ramifications of which were less serious [1197] because it was focused over a shorter period, people spent time in prison. Apparently, that will not be the case in Ireland.

In last weekend's Sunday Business Post, an unnamed spokesperson stated that the Government had been forced into granting aggravated damages. I hope and believe that is not the view of members of the Government parties who are at least as plentiful in compassion as are members of my party. However, I do not suggest that Fianna Fáil has any monopoly in that regard. It is sad that it took much haranguing and badgering during the past two and a half years before the Minister for Health could accept that fact. This again indicates that something is wrong and rotten in the way we do our business. I believe the Minister's instincts would have been as generous as mine in respect of this matter but why do politicians always find themselves cast in the role of defending the indefensible? The victims of this scandal are entitled to the best the State can do for them because it has done the worst it can do to them.

The magnitude of the U-turn on the statutory tribunal is considerable because not so long ago the Minister for Health was completely against such a tribunal. Nonetheless, I welcome that turnabout because it is good that a politician can listen to the arguments put forward and reverse his decision, even belatedly, from negative to positive. I do not suggest that he is doing so for other than the best of motives. However, it is extraordinary that this debate has focused on the contributions of a number of spokespersons in the Lower House rather than on the important issues.

Last week the Minister for Health referred to annual inspections of the BTSB. As a result of this scandal, the findings of inspections of any of the bodies involved in this matter should be published as early as possible. I am sure the Minister will move in that direction and, if he has not already done so, I ask him to make a clear commitment in this regard.

We are discussing not only the largest scandal to befall the State but also one of the saddest matters with which it has been obliged to deal. An extraordinary thing occurred at one of my clinics yesterday — I will investigate the facts before communicating with the Minister — when a man informed me that he is a hepatitis C victim. He stated he had discovered this by accident when the doctor examining him in hospital went to wash his hands and left the man's file open on his desk. I do not know the exact details and facts of the case but I will communicate with the Minister about it.

This matter returns to a point I raised in the past on which I had intended to focus primarily today. Within the public service there is a pathological obsession with secrecy. There is also an unhealthy attitude and absolute view among those employed as public sector administrators in State-sponsored bodies, semi-State bodies and [1198] the Civil Service that they have an enormous monopoly on wisdom. So many disastrous mistakes have been made in public administration that it is time we recognised the fallibility of those institutions. I winced when I saw on television last week a senior medical personage, associated until recently with the BTSB — it would not be fair to name him — haranguing politicians for debating this issue and suggesting that in so doing we were undermining confidence in the board. As the Minister said, the BTSB is our only source of blood. We are not suggesting that the public should lack confidence in that institution, we are highlighting the deficiencies which existed in the past and the urgent need to bridge the gulf between the board and the public.

I hope we can learn from this case. I wish we could walk away from political recrimination — I have engaged in it today because if one side calls the other a name, it will respond. This is stupid and makes no sense. What we should do is learn the lessons and ensure no more horrors will be visited upon us.

Ms Honan: I welcome the opportunity to contribute to this debate. When the report was published almost two weeks ago I put myself in the shoes of the victims who had contracted hepatitis C as a result of the negligence of a State board and in that context I found the report's language measured and bland. It used the words “adequate”, “inadequate”, “reasonable” and “inappropriate” to describe what everyone regards as the greatest health scandal in the history of the State. If I had been a victim I would have been angry at the report's descriptions of the actions of the major players in the BTSB and the Government. The criminal negligence which led to the catastrophe was described by the judge as resulting from “undue emphasis... an undue and unsupported belief... and the reluctance to admit the possibility of having been wrong”. After all the shocking evidence we heard at the tribunal I expected the report to be stronger. Perhaps this is the language of judges when dealing with the facts before them, but considering the appalling tragedy which had taken place one had expected something different.

I am glad the Government has at last acceded to the demand for a statutory tribunal, whose terms of reference were published last Friday week. The motion called on the Dáil to commend the Government's acceptance of the recommendations and to commend the Minister for Health for arranging the expeditious publication of the report. Since then, due to the Opposition's action in amending the motion and the interventions of a number of its own Members, the Government was forced to accept that a statutory tribunal was needed. As with everything which has been achieved since the scandal first broke over three years ago, it has had to be dragged from the Government and comes about as a result of the [1199] courage of the women of Positive Action, particularly the late Brigid McCole.

When this first emerged none of us expected it to have the consequences which have since unfolded. It was seen by the Government as a problem which could be dealt with as quickly as possible. The women would be herded into a compensation tribunal, paid off and that would be the end of the matter. We would never have heard the truth about what happened but for the courage of these women. It has been a long and hard battle, with all the might of the State pitched against them. Health provisions were put in place, but it took a long time to get exactly what the women wanted.

From the beginning they demanded a statutory compensation tribunal; they were told they could have everything else they wanted but it could not be statute based. They were told that if applications for compensation were not received by last June they would not have an opportunity to go before the tribunal. That closing date was set in order to frighten the women and force them into the tribunal. If they did not follow that path they, like Brigid McCole, would be hounded by the State to the Supreme Court and pursued for costs if they did not win. It is totally unacceptable that this was done to women who contracted a life threatening disease due to the criminal negligence of a State board. If this had happened in any other country we would have been shocked, but it happened here with the compliance of our Government.

No one has accepted responsibility for this shocking tragedy. These appalling and unforgivable breaches of duty and trust have cost some lives, shortened others and brought the shadow of tragedy to almost 2,000 families throughout Ireland; but only the victims have paid the price for this appalling scandal. No one has been brought to court except Brigid McCole, who was mercilessly bullied by the State into revealing her identity when all she wanted was the dignity of privacy in taking her case. No penalty has been exacted from those who, through their actions and inaction, decisions and indecision, set the stage for this tragedy. Some of them left office with a golden handshake, other received cosy retirement deals. Some were moved sideways within the structures of the State, holding onto their salaried positions and retaining their pension rights.

We should contrast the treatment of those responsible for the Irish infections with that of the French officials responsible for contaminating their blood supply with AIDS, who ended up in jail. We have a culture whereby those in whom we place our trust and who hold the highest public offices are absolved from full responsibility for their actions. In every major scandal to date, those responsible have walked away. At a time when we are discussing zero tolerance of crime it is ironic that there is 100 per cent tolerance of [1200] gross negligence, malpractice and worse among those who hold high office.

I am glad the Government has at last conceded the women's demands for a statutory tribunal, but it has taken over three years for this to happen. After the publication of the Finlay Tribunal report I would have expected more generosity and a greater willingness to acknowledge what happened and the State's responsibility in that regard.

As previous speakers said, many Ministers for Health were in office between 1975 and 1994 and it is unfair to blame the two most recent Ministers for this tragedy. I do not blame any Minister for Health for the infection of the victims with hepatitis C, but the actions of Ministers since the issue came into the open must be subject to scrutiny. My main criticisms of the Minister, Deputy Noonan, relate to the hounding of the late Brigid McCole through the courts and the threat made to the other women that if they did not take part in the compensation tribunal they would be pursued by the full might of the State. That is totally unacceptable. No member of the public elects politicians to Dáil Éireann to act in such a manner on his or her behalf. No one would insist that the State should force Brigid McCole to disclose her identity in court. That is not the way Ministers should behave. Perhaps they believed it was their function to defend the institutions of the State rather than the people. If that was their interpretation they were wrong. I do not believe we have received an adequate explanation from the Minister for Health why the full rigours of the State were employed in pursuing the late Mrs. McCole. She was within hours of her death when she was offered a settlement and an apology from the BTSB. Even at that stage she was told that if she refused it she would pursued to the Supreme Court and costs against her would be sought if her action failed. I hold the Minister responsible for the actions taken in this case.

The former Minister for Health, Deputy Howlin, was not responsible for the infection of the victims of hepatitis C but he had a duty to disclose that there was a second source of infection when the scandal first came to light. I have spoken to women who contracted hepatitis C as a result of the second infection in the early 1990s. They were treated in a shocking fashion by the BTSB. It should never have happened. Had it been disclosed at the beginning that there was a second source of infection it would not have happened. The Minister for Health is the person with ultimate responsibility for health matters and for the agencies under his or her control. The Minister, Deputy Howlin, has a responsibility in this regard and he owes us an explanation.

While examining my files on this issue I came across a copy of a letter which I raised in the House on the first occasion the hepatitis C scandal was discussed. The letter was sent on 21 February 1994 by the BTSB to all GPs with regard to the discovery of anti-D being infected with [1201] hepatitis C. It is extraordinary to compare what was known then with what we know now and how the scandal has unfolded. It states:

Dear Doctor,

The Blood Transfusion Service Board...is carrying out a lookback study of Hepatitis. Arising from a recent BTSB study, we have reason to believe Rh Negative women who received Anti-D Immunoglobulin in 1977 may have been exposed to the Hepatitis C virus. A small number of recipients may have contracted the virus, although they may have continued to feel perfectly well after receiving Anti-D. We know that there is a risk of chronic asymptomatic carriage of this virus which may eventually cause significant liver disease. However, recent reports support intervention and therapy in the pre-symptomatic phase.

It is important therefore that Rh D Negative women who received Anti-D in 1977 are afforded a screening test for Hepatitis C. Women who received Anti-D at other times may also be tested. The BTSB is committed to contacting these women with a view to offering such testing at designated clinic locations. A national campaign is being launched on Tuesday 22 February.

It is extraordinary that three years later the BTSB still has not seen fit to contact all the people they know have been exposed to suspect batches of anti-D or batches which it knows were contaminated. The public would be astonished to know that the BTSB did not make direct contact with each woman who had been treated with the batches involved as soon as it became aware of the contamination.

From the beginning the BTSB's primary duty ought to have been to the women who were infected. This was not the case. The women have faced an uphill struggle every step of the way in trying to get information. Making direct contact with every woman exposed to the contamination ought to have been the first step in the BTSB's response to the crisis. It said it would do so in February 1994 yet it still has not done so. I would have thought that, on assuming office with a brief to clean up the BTSB, its new management ought to have contacted each potential victim directly and without delay. It has failed to do this. This indicates a lack of awareness of the dreadful fate which hepatitis C has visited on the infected women and their families. Until the BTSB contacts everyone treated with infected batches and tests them accordingly we will not know the full extent of the infection.

Some people are discovering only now that they have been infected. As late as last week I was contacted by the husband of a woman in my constituency who was tested for hepatitis C only recently and has been found positive for antibodies and virus. She assumed that she would [1202] have been notified by the BTSB that she had been exposed to a contaminated batch. When she approached the BTSB she found out that it knew the batch numbers and that she had been exposed to it but it had not contacted her. I ask the Minister to ensure that the BTSB is proactive in its look-back programme and that it accepts its duty to inform every woman who has had contact with a suspect or an infected batch. It is important from a woman's health perspective and what an individual decides to do once contacted is her decision. However, the BTSB has a duty to inform her.

I was contacted about the case of a former constituent of mine who died in January 1990 after a liver transplant. She was 38 years of age and she left behind a husband and six children, the youngest was just three years old at the time. She had a normal lifestyle but she became unwell gradually over a long period, starting with feeling tired and run down and culminating in liver failure in late 1989. She suffered symptoms during several years which we now know to be consistent with hepatitis C infection. She became unwell in 1987 and her husband had to take so much time off work to care for her and their children that he was forced to give up his job. Since then her husband's only source of income on which to raise his six children has been social welfare benefits. Their lifestyle has altered radically and they must forego many of life's necessities, never mind luxuries, in order to survive.

This woman attended her doctor and her local general hospital over the years where she was treated for various ailments. In September 1989 she became severely jaundiced and was admitted to the local general hospital. She tested negative for hepatitis A and B. She was detained in hospital for a month and then discharged. She was readmitted on 27 December 1989 with a recurrence of jaundice. She was transferred to St. Vincent's Hospital on 28 December 1989 and the referring consultant queried hepatitis C as a possible cause of her liver disease.

The doctors in St. Vincent's Hospital spoke to her husband about her lifestyle and asked if she had received blood transfusions. Her husband indicated that she had received transfusions during the birth of her children. At that stage they decided to perform a liver transplant if a suitable organ became available. The liver transplant operation took place on 8 January 1990 but two days later she died but the family has since discovered that she had a positive test for hepatitis C carried out on 4 January 1990 prior to her death. The family was not informed of this at the time. Her husband and children have had to suffer the stress and trauma of wondering if they have contracted hepatitis C since the hepatitis C scandal came to light in 1994. There was no counselling or support for the family. Their bereavement was compounded by the lack of information, understanding and support, be it moral, emotional, physical, psychological or financial.

[1203] The family asked me to raise this case because it is concerned that people who have contracted hepatitis C through blood transfusions are being dealt with in a different way from the women who contracted hepatitis C from anti-D. The family was astounded that it was told by Mr. Dunbar of the BTSB that if the cases of people who are deceased came to light in the look-back programme it was not the BTSB's policy to notify their families. The validity of the Department of Health allowing the Blood Transfusion Service Board to conduct a look-back programme for the board must be questioned.

I ask the Minister to take account of cases where the victim has died and the difficulty relatives have in pursuing their case. One difficulty they have is the testing that is now available but which was not available in 1990. The other difficulty is the limit of compensation that can be awarded. Families such as the one about whom I have spoken are only entitled to £7,500 in compensation. This is extraordinary considering all that has happened to them and what they have had to go through since the death of their mother. The Minister should reassess the work of the compensation tribunal to ensure that families are not insulted by paltry compensation sums of £7,500. The tribunal should have power to grant higher amounts than the courts in these special circumstances. No amount can sufficiently compensate the family. In dealing with the concerns of the Irish Haemophilia Society and the issue of HIV infection in the context of another tribunal, the Minister should ensure that outstanding issues relating to infection with hepatitis C not covered in the Finlay tribunal are addressed. Otherwise, the victims will never get justice.

Mr. Sherlock: Tribunals have had a bad press, often with good reason. The Finlay tribunal, however, has demonstrated that a tribunal can work quickly and produce a cogent report outlining all the salient facts and making practical recommendations. We owe Mr. Justice Finlay a debt of gratitude for the sensitive yet probing manner in which he conducted the inquiry into the worst public health scandal, and perhaps the worst scandal ever, in the State.

The hepatitis C scandal has provided ammunition for parties on all sides of the Oireachtas to score party political points. To watch the debate in the Dáil yesterday one would have thought politicians rather than ordinary citizens were primarily affected. There is a danger that the human dimension will be lost sight of in the debate. Sixteen hundred women, citizens who depended on the State to ensure a safe blood supply, have been infected with a medical time bomb. It has already claimed one victim, Mrs. Brigid McCole. Other victims fear that they may be living on borrowed time, whether measured in months, years or decades.

The tribunal report outlines what happened. It paints a picture of almost unbelievable incompetence [1204] and sloppiness over many years. To make matters worse we heard last week that a woman infected with hepatitis C was requested by the BTSB to give blood. This cannot be glossed over nor can the appalling mistakes which were made be airbrushed out of history. Lessons must be learned and have been learned.

Mr. Justice Finlay's recommendations when implemented, together with the steps already taken by the Government, will guarantee the safety of the blood supply and ensure that it is operated to the highest standards dictated by current medical knowledge.

I welcome the Government's decision to place the compensation tribunal, chaired by Mr. Justice Egan, on a statutory basis and to reappraise and amend the scheme to allow victims receive additional special damages. I welcome the Minister's assurance that those who have gone before the tribunal, or are currently before the tribunal, will benefit retrospectively from any changes. The course outlined by the Minister is the only proper response to the grave situation.

Financial compensation will help alleviate the material problems of the women and their families and provide them with peace of mind for the future. However, no amount of money can compensate these women for the physical, mental and emotional suffering which they have endured and continue to endure.

The twin challenges facing us are to ensure the future safety of the blood supply and, equally important, to enhance public confidence in that supply. Our voluntary blood supply is a great strength. However, the revelations surrounding the present scandal combined with irresponsible statements from some politicians have undermined confidence among donors and recipients. I was especially concerned to read a report in The Irish Times indicating that an increasing number of patients are reluctant to receive blood or blood products even when they are vital to treatment. Such concerns are unwarranted in view of the measures taken by the Government to ensure the safety of the blood supply. I appeal to those in need of blood or blood products to rely solely on the advice of medical practitioners.

Last week Senator Henry reminded us that, during the 1960s, the primary cause of death among women of child bearing age was haemorrhage. Blood transfusions prevent that tragedy. We must ensure that we do not turn the clock back in expressing our outrage at what has been done to the women infected by hepatitis C.

Minister for Health (Mr. Noonan, Limerick East): I thank the Senators for their contributions and wish to refer to a number of issues raised over the past week and in the House today.

In my speech I referred to the recent incident in the BTSB involving the contacting of a victim infected with hepatitis C with a view to obtaining a blood donation. I wish to state again that mistakes such as these, even when there is no risk to the blood supply, are unacceptable. The BTSB [1205] has a statutory obligation to ensure an adequate supply of blood. When a situation arises where there is a shortage of blood or a particular blood group is needed urgently, a comprehensive list of all donors containing relevant information, including their donor status, is produced for the donor organising department. This list is used by the clerical staff to make telephone contact with the donors in the local clinic area to boost clinic attendance. Such a list was produced by the BTSB for the evening of 3 December 1996 for the local clinic because the BTSB needed to increase donations. The clerical officer who telephoned this donor who had been diagnosed positive for hepatitis C did not note the deferral information on the list. During the telephone call the error was identified and the clerical officer apologised to the donor. The following day, 4 December, the donor's husband telephoned the BTSB to complain about the matter. It was investigated by one of the doctors on the staff and the donor's husband was telephoned on 6 December. An explanation for the error and an apology was given. However, the donor's husband again telephoned on 11 March 1997 requesting a written explanation of the incident. The BTSB responded in writing on 21 March 1997 expressing regret to the family.

Arising from this incident, the staff in the BTSB have been urged yet again to be extra vigilant when checking lists so that all relevant donor history is noted. Likewise, as a result of the meeting which I had with the chairman and chief executive officer of the BTSB last week, that organisation is implementing necessary changes to their computer system. When I gave this explanation previously, persons asked me why donors who had been deferred were listed at all. The reason is that donors who have been previously refused at blood clinics continue to turn up. The BTSB has examples of people who have been screened out because they were HIV positive returning to clinics and offering blood. The way in which the controls operate are that those who are eligible to give donations are listed, those who are deferred indefinitely are listed and those who, because of colds, flus or whatever were deferred for three to six months are also listed. It is a failsafe mechanism to ensure that somebody whose status is deferred and who turns up to give blood has their blood refused at that point. Any mistake such as this is unacceptable. The BTSB will once again review its systems but there was no danger at any point that infected blood would get into the blood supply arising from this incident.

I would also like to refer to the donor selection procedure currently operating in the BTSB and whether these procedures ensure public safety and confidence. As a result of the incident last week, the general public are understandably concerned about the safety of the blood supply. I reiterate that there was never any risk to the safety of the blood supply arising from this incident.

[1206] The number of donations with which the BTSB is dealing is very big. Approximately 170,000 blood donations are collected annually by it. There are well defined steps taken by the BTSB in relation to donor selection and donor eligibility. As Senators are aware, blood donations in Ireland are on a voluntary, non-remunerated basis. Only donors in good health are accepted and the decision as to whether a potential donor is suitable rests with the medical officer who evaluates the donor on the day of donation. The donor questionnaire must be satisfactorily completed after the donor has read and fully understood the special notice concerning transmissible diseases. Where there is a doubt about the suitability of a donor, the donation is not accepted.

The first step in ensuring that all those receiving blood are not put at risk at any time is to take maximum care when selecting persons who donate blood voluntarily. The guidelines for donor selection by the BTSB medical officers are revised regularly in line with the UK National Blood Authority Guidelines for medical assessment of donors and the Council of Europe guide for preparation, use and quality assurance of blood components and blood collection. These guidelines have a dual objective — to protect the recipient from any ill effect through transmission of disease by blood transfusion and, secondly, to protect the volunteer donor from any harm to his or her health. I am assured that, in applying these guidelines, the BTSB is among the most stringent transfusion centres in the world, a fact that is attested to by all objective commentators internationally. I am further assured that the standard of testing which the BTSB now applies to the testing of blood donations is fully in line with best practice in Europe. The average annual deferral rates of donors attending clinics is between 13 and 15 per cent which is among the highest in the world.

I now turn to an issue which has arisen since the publication of the report of the tribunal of inquiry. It relates to 74 anti-D recipients from 1977 who had an episode of jaundice. In Appendix G of the tribunal of inquiry report it is stated that:

We [the BTSB] are thus aware of 74 recipients of 1977 anti-D who had an episode of jaundice at that time which is most likely to be related to exposure to hepatitis C. As these persons do not show any reaction on laboratory tests for hepatitis C an epidemiology study is planned to investigate transient infection which has subsequently cleared.

The BTSB has confirmed that the 74 women referred to in the tribunal's report have all been contacted and tested and are all antibody negative. The epidemeiology study in relation to transient hepatitis C infection will be undertaken.

The issue has been raised as to whether a national epidemiology study to determine the prevalence of hepatitis C in the population at large should be undertaken. This would be a [1207] major logistical and organisational undertaking. Given that the majority of the general population has no known risk factor for hepatitis C infection, that there is no constructive intervention such as vaccination which can be used and that there exists no satisfactory cure for hepatitis C, the ultimate value of the information produced by a national survey would be limited.

Apart also from those who contracted hepatitis C through infected blood or blood products and apart from other groups with well know risk factors, I am reliably informed there is no evidence to suggest that the prevalence of hepatitis C in this country is any higher than in other comparable countries. Accordingly, there are no proposals at present to conduct a national survey to establish the prevalence of hepatitis C in the population as a whole. It is an issue which requires further examination, however, and I propose to seek the advice of the statutory consultative council on hepatitis C which I established last November and which recently held its first meeting. The remit of the consultative council includes the monitoring of matters relating to research and has a broad spectrum of expertise including nominees of the four main representative groups, namely, Positive Action, Transfusion Positive, the Irish Haemophilia Society and the Irish Kidney Association.

Senator Henry commented on the delay in introducing the tests in 1991. Apart from what is in the report, I cannot shed any further light on that. I know it is an issue which has concerned Senator Henry for some time and it is dealt with comprehensively in the report. We must learn from incidents such as this. The practice which has obtained in this country for so long in simply following UK procedures and practices must be discontinued. We must be in a position, and must have the resources, to ensure that independent decisions are made. At the time, there was a great reliance on what was happening in the UK because neither the Department nor the BTSB had the critical mass of medical expertise which would be necessary to make a series of independent decisions in respect of medical matters.

The decision to transfer Pelican House to the campus of St. James's Hospital will rectify that to a large degree. As Senator Henry would know better than anybody here, if professionals, particularly medical professionals, are isolated for a significant period of time and have to work far removed from medical colleagues with similar expertise, they frequently become rusty, to put it in lay terms. It is necessary to have a critical mass of persons, not only those working in the area of the blood transfusion service but also haematologists, working in a major acute hospital where the delivery of blood by way of transfusion is part of their day to day work. It is the interplay of the professional expertise between the two on the campus of a major acute hospital which will give us the critical mass to enable the BTSB in future to advise the Department of Health when particular [1208] decisions should be taken in respect of matters which are pertinent to the blood supply.

Concern has also been expressed that all recipients of potentially infectious blood and blood products should be traced. The BTSB has a substantial duty of care to trace each and every one of these recipients. To fully comply with this duty an experienced and professional team has been put in place with a view to achieving the objective of the targeted look-back programme. This dedicated team comprises medical, nursing, clerical and administrative support.

The modus operandi of the targeted look-back programme is to identify the infected issues and to trace the issue to a named recipient; the person is then located and arrangements for testing are made in as sensitive a manner as possible. Extensive efforts are being made to trace all the issues of blood and to locate the named recipients.

Specific concerns have been expressed as to why the BTSB has not contacted persons whom they know received potentially infectious blood or blood products. In a number of cases, the BTSB only has the name of recipients and no other information. In other cases, the name and the date of birth is known and the person's GP has been contacted but no current addresses are available. I reiterate that every conceivable effort is being made to first identify and then locate such recipients.

Concern has been expressed that a number of persons who received anti-D in 1977 have not come forward for screening. In 1977 and 1978, a total of 17,214 vials of anti-D made from plasma, which included that of patient X, were issued. Of these 4,062 vials of anti-D were issued from the 12 batches which were prepared after patient X became jaundiced. The Finlay report has summarised various efforts in relation to the targeted tracing of those persons who have received these infected vials.

At the request of the tribunal of inquiry the medical consultants at the BTSB prepared a document which is summarised in Chapter 5 of the tribunal's report and reproduced in full at Appendix G. In relation to recipients of infected 1977 anti-D, the document states: “we have previously directly invited known recipients of infected 1977 Anti-D for Hepatitis screening. However, a number of recipients have not yet presented for testing and we [the BTSB] are therefore following this up with individual recipients and hospitals with specific attention to recipients of PCR positive batches”. As I said earlier, all recipients of potentially infected blood products are, as far as possible, being traced under the targeted look-back programme.

Finally, to ensure that no one escapes the net and to ensure that all recipients of blood transfusion and blood products are given the option of being tested for hepatitis C, as I have already mentioned, I announced the national optional testing programme on 12 September 1995. Testing is free of charge to all and has been regularly advertised in the national media.

[1209] Former Chief Justice Finlay has produced a report of great clarity and candour; it does not shirk any of the hard questions posed in the terms of reference, and it has thrown clear light and imposed order on medical, administrative and legal controversies which were previously shrouded in mystery and confusion.

Before I thank the generality of Senators, I thank, again, Senator Henry for bringing to the attention of the then Minister for Health the fact that the replacement anti-D product was not then licensed by the FDA. Senator Henry had made inquiries in relation to this matter and her interest and diligence in this and other matters should be commended by all of us.

I welcome unreservedly the report of former Chief Justice Finlay. I hope that the acceptance of the motion by this House will mark a significant step forward in dealing with these tragic events.

Question put and agreed to.