The director of the Blood Transfusion Service failed to bring to the attention of his board two of the recommendations from the Council of Europe in mid-1993, one of which said haemophiliacs should be informed of the risk of getting AIDS from blood products.
The other recommendation, the tribunal heard yesterday, was that the use of imported blood products made from large plasma pools should be avoided when possible.
While other recommendations by the council were acted upon, there was no record in the minutes of BTSB board meetings of the then director, Dr Jack O'Riordan, who attended the Council of Europe meeting, telling his board of these two recommendations.
Counsel for the Irish Haemophilia Society, Mr John Trainor SC, asked the BTSB's deputy medical director, Dr Emer Lalwor, why there was no record of the two points being brought to the attention of the board.
Dr Lawlor said the task of informing haemophiliacs about possible risks posed by products was one for treating doctors, not the BTSB. She added that treating physicians at the time played down the risk of haemophiliacs contracting HIV and AIDS.
She also said that unfortunately at this stage most of the damage was already done. By early 1983, 85 per cent of those who turned out to have HIV had already been infected.
Mr Trainor said that instead of imports being curtailed, they increased. He suggested to Dr Lawlor that a number of people might have been spared infection if the recommendations were adhered to. "A small number, yes," Dr Lawlor replied.
Counsel said if so much as one person was spared infection and if just one family was spared their grief, it would have been a step worth taking.
Mr Trainor suggested the BTSB should have immediately stopped distributing imported blood-clotting agents. Dr Lawlor said perhaps the BTSB should have done this but even if it had the products would still probably have come into the State.