It would be bad enough if the BTSB had just not thought of carrying out a look-back programme to see what happened to the blood of HIV-positive donors. Worse, it seems the agency considered the idea and decided not to bother.
Evidence yesterday showed the board's senior medical consultants compiling a list in July 1987 of donors who had tested positive for the virus since the introduction of HIV testing in October 1985. On the list was an individual, subsequently called Donor A, who was recorded as having donated blood on July 16th, 1985.
There could have been little doubt that this donation was potentially infectious and, as a result, its recipient could have been infected with HIV. Despite this and the fact that look-back procedures were running in Britain, which the BTSB followed on almost all these matters, no procedures were initiated here.
In fact, the board decided to adopt a look-back policy only in April 1993, and it was not formally initiated until September 1996.
Asked why a programme did not start nine years earlier when Donor A's blood donations were identified, Dr Emer Lawlor, the blood bank's deputy medical director, said she did not know but she had no doubt it should have been done at the time.
The recipient of Donor A's blood was the woman known to the tribunal as the Kilkenny health worker, a former nurse at St Luke's Hospital, who was infected through a blood transfusion in July 1985. Married with no children, she discovered independently of the board that she was HIV positive in December 1996.
In fact, the board left it so long to introduce a look-back programme that by the time it sent out a list to hospitals of 31 potentially-infected blood products, derived from seven HIV-positive donors, the bulk of the documentation which would have assisted in tracing them had been destroyed. All pre-1986 BTSB dispatch records were shredded without authorisation.
Offering suggestions as to why the look-back was not started earlier, Dr Lawlor said there was a feeling that the tracing system was not working well in other countries. Moreover by April 1995, when she found out to her "dismay" that a look-back had not already been done, the risk of an infection was considered "infinitesimal" and the board had other priorities.
From evidence given to date, however, it seems the over-riding factor behind the board's reluctance to introduce a look-back was its fears of negative publicity.
On Wednesday the tribunal saw documentation showing senior BTSB officials saying the board "should not be seen to be taking a lead in testing for AIDS" and that "the priority for the blood transfusion services must be to dissociate themselves from any publicity linking them with the transmission of AIDS".
Yesterday the board was recorded expressing its serious concern in September 1989 "about the potential legal and public relations aspects" of a look-back programme.
The tribunal has already heard evidence to suggest the BTSB sought to cover up its role in the infection of seven haemophiliacs with locally-made Factor 9, an issue about which, Dr Lawlor admitted yesterday, there was "a sort of denial".
Denial also seems to be a fitting word for the board's approach to the look-back issue. Instead of taking what Dr Lawlor conceded was the obvious course of action, it waited and waited, and seemingly hoped no positive cases would turn up.
Towards the end of yesterday's evidence Dr Lawlor described how the blood supply "just collapsed" in 1995 as public confidence in the BTSB began to wane. For that, it seems, it only had itself to blame.