A new report has recommended there be a clear assignment of responsibilities and accountability for management in all areas of the Irish Blood Transfusion Service (IBTS).
The delay in notifying donors on first testing positive for hepatitis C between 1991 and 1994 was examined in an independent report by international expert Bernhard Kubanek.
The report, which was commissioned by the IBTS, criticised two approaches at that time in Dublin and Cork to testing, confirming positivity, and informing donors. It said that after the Finlay blood tribunal, a number of changes in management were introduced.
"However, a look at the organogram [a graphic representation of an organisation's structure] of today still shows rather tangled reporting relationships," the report said.
"It is difficult to understand how one blood transfusion service could allow two different approaches to such essential questions as to testing, or rather confirming HCV positivity, and to informing as well as referring the donors for further medical evaluation after the experience with HIV in transfusion medicine in the late 1980s," it said.
The provision of safe blood components could not be different in Cork and Dublin. It should be directed by one responsible person and under one quality system.
Responding, the IBTS said it had developed a single national quality assurance system which ensured that policies and procedures were carried out within a unified system.
The report said HCV screening was introduced in Dublin and Cork on October 1st, 1991. In Dublin, from January 1992, all donors considered positive were notified in about eight weeks. In Cork it took until November 1993 to recognise that donors should be notified and referred.