The 197-page Finlay report published last March contained strongly-worded criticism of the Blood Transfusion Service Board (BTSB) and blamed the negligence of former staff members for the infection of 1,600 men and women from contaminated blood products.
In his report Mr Justice Finlay found that the primary cause of the infection of the blood product anti-D with hepatitis C was the use of plasma from patient X. In using the plasma the BTSB had been "clearly in breach" of its own standards.
The BTSB had failed to report reactions to this anti-D, failed to investigate other possible cases of infection and failed to recall contaminated batches of anti-D, the report found. It had acted unethically in using patient X's plasma without asking her consent.
The report also found that the BTSB had used plasma from donor Y which had tested positive for hepatitis C. The response of the board to the December 1991 letter from the Middlesex Hospital confirming that patient X's plasma was hepatitis C positive had been "completely inadequate and non-existent," it found.
The Department of Health was also criticised. It should have adopted the "lookback programme" recommended by hepatitis experts in 1994. Its failure to do so represented inadequate and inappropriate supervision.
Mr Justice Finlay placed the major responsibility for contamination of the anti-D product on the "total failure" of named officials of the BTSB to maintain standards of donor selection.
One of these was Dr Jack O'Riordain (83), former national director of the BTSB, who bore the "major responsibility" for the infection of anti-D with the hepatitis C virus.
Another was Ms Cecily Cunningham, principal biochemist at the BTSB at the time the anti-D infection occurred. The report found that Ms Cunningham, who ran the laboratory where the antiD was produced, "bore an important and serious responsibility" for the product being infected.
In 1991 she ignored warning signs arising from a form of positive hepatitis C test "due apparently to indifference". At the time of the report Ms Cunningham was on sick leave but she no longer works at the BTSB.
Dr Terry Walsh, the most junior medical officer at the BTSB at the time, was found to have neglected his duty when he failed to recommend against using patient X's plasma as soon as he learned of her jaundice and hepatitis.
In 1991 he received a letter which confirmed patient X's plasma was hepatitis C positive but, said the report, he appeared to have a "vague hope that by ignoring the problem it would go away."
Dr James Kirrane, then a part-time consultant with the BTSB, was criticised for not pressing for an investigation after he was told in the Mater Hospital in 1977 of patients who had developed jaundice after being given anti-D.
The report, which was forwarded to the Director of Public Prosecutions by the then Minister for Health, Mr Noonan, also made several recommendations which the Government of the time decided to accept. It was recommended that Pelican House be closed, with the BTSB relocated to St James's Hospital.
The BTSB, the report suggested, should be subject to two full inspections annually, and arrangements have since been made for more regular inspections.
Mr Justice Finlay's recommendation that laws should be introduced to make non-reporting of abnormal reactions to blood or blood products a criminal offence has yet to be implemented.
At the time of the report last March, a legal source contacted by The Irish Times said that prosecutions were unlikely against the BTSB, any former employees or any Department of Health officials. "There is no culture in this country of people being brought to book for this type of thing," he said.