Victim's story: Deirdre told the tribunal that her husband, Declan, had mild haemophilia A - so mild that he had never received any form of treatment prior to May 1984. In April 1984 he was admitted to St. James's Hospital for minor surgery.
After the operation it was recorded in his file that he should have daily treatment with the Factor VIII clotting agent in a particular form (cryoprecipitate) for one week.
But approximately three days after the operation, the treatment was changed to a different form, Factor VIII concentrate. Declan was infected with both HIV and hepatitis C and later died.
The tribunal believes the probable source of his infection was this treatment with Factor VIII concentrate.
No explanation is recorded in Declan's file for the decision to change his treatment.
The decision was apparently made by a junior doctor without any reference to any consultant.
This change was "completely contrary" to a policy adopted in December 1983 to protect persons with haemophilia.
The tribunal believes that what occurred happened without reference to Professor Temperley and he was not involved in the change of treatment.