ON JANUARY 10th this year, nearly two years after the hepatitis C scandal became public, a woman presented herself to the Blood Transfusion Service Board, offering to donate blood.
Her blood had previously been used by the BTSB to make anti-D scrum, and the BTSB had known for some years that it had been one of the main sources of the infection of anti-D with the hepatitis C virus. Yet, even after the press conferences, the Dail debates and the Expert Group report into the scandal, no one in the BTSB had thought to tell the woman - now known as patient Y - that she should not give blood.
It has become clear this week that not only were there terrible problems with the operation of the BTSB in the 1970s and the 1980s, but even now the organisation has not fully come to terms with the consequences of its recent history.
The unimpressive response of the BTSB's new management to the revelation that up to 15 people may have been at risk of contracting HIV from contaminated blood products suggests that the process of transforming a deeply discredited organisation into a model of public accountability is not yet complete.
The HIV problem admittedly, has its roots in the old regime. It came to light last Monday with the revelation that a nurse at St Luke's Hospital had been infected with HIV by a blood transfusion in 1985. She had received one of 16 potentially HIV-infected units of blood that had been issued by the BTSB at that time.
In September, the BTSB wrote to all relevant hospitals trying to trace the other recipients of these units, but failed to mention HIV at all, giving the impression the queries related instead to hepatitis C. It also failed to tell the Minister for Health about its fears.
The HIV problem is just another manifestation of the appalling breakdown of basic procedures in the BTSB that is amply demonstrated by the case of patient Y. As the hepatitis C tribunal learned this week, she started plasma exchange treatment at St James's Hospital in Dublin in August 1989, and the following month was herself infected with hepatitis C by a unit of plasma she received from the BTSB. That, in turn, had come from a donation of blood made by a man who had a history of drug abuse. After she became infected, the BTSB took 12 more donations from her and froze them for later use.
In January 1991, the principal biochemist at the BTSB, Cecily Cunningham, decided to use some of this frozen plasma to make more anti-D. She asked one of the board's medical consultants, Terry Walsh, to contact patient Y and have her tested for HIV and hepatitis B.
What happened next is, even by the BTSB's standards, extraordinary. First, even though Mrs Cunningham had asked for patient Y to be tested, she proceeded to make and issue anti-D from her plasma long before the tests were actually done. She told the tribunal that since "we were a bit short" of anti-D "I just plodded ahead." Nine batches were issued without any testing of the donor.
That, however, was only the beginning. From October 1991, when a specific hepatitis C test had finally become available, the BTSB was also supposed to test each donation that was going to be used for making anti-D for that virus. The first sample of patient Y's blood tested on October 2nd and 3rd, 1991, showed positive for hepatitis C on both occasions. Later, in July 1992, two more tests on patient Y's plasma also gave positive results.
At this time, the BTSB had clear rules for what to do in such a situation. Its "standard operating procedure" document stated that "any donation which fails to give a negative reaction . . . will be withdrawn from stock, together with any product containing a component of the donation."
Even if the initial positive result turned out on subsequent testing to be wrong, the donation was still to be discarded and destroyed.
But these rules, designed to protect the public, were simply ignored, because the BTSB assumed that the positive results must be false. The samples were not even referred, as they were supposed to be, to the virus reference laboratory in UCD for more sophisticated tests. Anti-D made with patient Y's plasma continued to be issued as late as 1994.
As a result, 43 people were infected because of the use of patient Y's plasma and another 30 to 40 have hepatitis C antibodies in their bloodstream. This was all the more appalling because, just at this time, the BTSB received definite evidence that anti-D it had made in 1976 and 1977 and issued to thousands of women was infected with hepatitis C.
On August 15th, 1991, Middlesex School of Medicine asked the BTSB for permission to test samples of plasma which had been sent it to it by the BTSB in 1977, for hepatitis C. On December 16th, Jeremy Garson in Middlesex faxed a letter to Dr Walsh, now the chief medical consultant at the BTSB, saying the tests strongly suggest that hepatitis C-contaminated anti-D was responsible for the outbreak of hepatitis which had occurred in Dublin in 1977.
Two people at the BTSB knew about this fax. One was Dr Walsh who, as he told the tribunal, began to gather factual material in response to queries from Dr Garson but failed to contact Dr Garson again. Dr Walsh took early retirement from the BTSB when the hepatitis C scandal became public, and told the tribunal this week: "I can't really put into words how sorry I feel" about his failure to act on all the many warnings of disaster that he received from 1977 onwards.
The other was Dr Emer Lawlor, currently a consultant haematologist at the BTSB. When Dr Walsh told her about the Middlesex fax, she "realised that there was a problem". She and Dr Walsh agreed to discuss the matter further after Christmas, but in fact "he never came back to me and I forgot all about it .. . It just totally slipped my memory ... It is something that I deeply regret."
She later told John Rogers SC, for Positive Action, that "about 30 people wouldn't have got the virus had that fax been acted on."
And yet, as the HIV problem revealed this week shows, it was not just anti-D that was involved in this sorry saga. The whole blood supply was being put at risk. One of the grimmest facts to emerge this week was that 113 of the women who were infected by anti-D themselves subsequently donated blood, some of them many times. This blood was itself used for transfusions and to make more blood products.
In this chain reaction, over 400 blood products infected in this way were issued, each of them carrying an 80 per cent risk of infecting those who received them.
One of the most worrying aspects of this week's evidence is that it suggested that the new management of the BTSB has not, even now, tried to discover what precisely had gone wrong and how Mrs Cunningham could possibly have manufactured and issued anti-D and Factor 8 (a blood product essential to haemophiliacs) which had not been properly treated or tested.
It should never be forgotten that when the new-model BTSB began its look-back programme to identify women who had been infected with hepatitis C by anti-D, it gave many of the women being screened the impression that they, and not the BTSB, might be at fault.
Women arriving for tests, often with their husbands, were asked to give details of their sexual partners, tattoos, ear-piercing and intravenous drug use. Yet the BTSB knew with certainty that the cause of any hepatitis C infection these women might have was none of these things but a product they had received from the BTSB itself to help them protect any future children they might have.
And when those same women tried to get information from the BTSB they found, as Jane O'Brien of Positive Action told the tribunal this week, "a complete unwillingness to answer those questions...there was a deliberate attempt to keep women isolated and not in contact with each other".
Without the tribunal, it is doubtful that that isolation would ever have broken, that the apologies heard for the first time this week would ever have been made, or that the depth of disarray at the heart of a vital public service would ever have been revealed.
