One of the consultants most involved in the treatment of haemophiliacs told the tribunal yesterday that he felt "let down" by the Blood Transfusion Service Board for not giving adequate information on the products which it was supplying to hospitals at the time of the HIV crisis.
Prof Ernest Egan, a consultant haematologist at University College Hospital Galway, said he believed it was the duty of the board, as the producer and supplier of products, to keep those involved in treatment informed of developments.
He said he found it "very disappointing" to learn only in August 1986 that a number of haemophilia B patients had tested positive for HIV as a result of using non-heat-treated Factor 9 made at Pelican House. This was at least three months after the board was aware of the infections.
In a letter replying to Prof Egan's concerns in September 1986, Dr Terry Walsh, a consultant with the board, said he thought he had discussed the Factor 9 issue with Prof Egan on one of his visits to Galway.
Asked what recollection he had of this, however, Prof Egan said: "None whatsoever." He added: "I could not imagine just sitting on that information if I had received it."
Prof Egan's concern with the BTSB's handling of the Factor 9 issue stretched back to January 1986, when he wrote to the board complaining that he still had unscreened and non-heat-treated product in stock when other hospitals, such as St James's in Dublin, were using heat-treated Factor 9.
He said his concern was that Galway was not getting the same products as other centres and, as a result, was "a bit out of step."
His letter to the board appeared to have been written two days after Dr Egan had administered 1,700 units of non-heat-treated Factor 9 (batch number 90753) to a patient in Galway. The batch was subsequently found to have been infectious, although the patient, along with all other patients in Galway, avoided contracting HIV.
Prof Egan said that subsequent to writing the letter he ceased using BTSB Factor 9 until Pelican House replaced his stocks with heat-treated material in May.
He said his understanding was that the replacement product was both heat-treated and screened for HIV. However, this was not the case, as the BTSB had yet to produce a screened Factor 9 product.
Prof Egan said he felt he had been let down by the service, as he had been provided with a product which was different from the specification he had asked for.
He agreed that he felt a "double disappointment", first, at the board's failure to supply him with the product he desired and, second, at its failure to inform him of the infections which had been caused by Pelican House Factor 9.
In evidence to the tribunal, Dr Walsh said Prof Egan should have received a notice in January 1986, sent by the board to all hospitals, recommending that only heat-treated Factor 9 be used.
Prof Egan said he had no recollection of receiving the notice and he found it "inconceivable" that he could have received it and not acted upon it.
