Haemophiliacs meeting today to consider the Lindsay Tribunal report feel dejected and bitter about its findings, writes Joe Humphreys.
The publication of the Lindsay Tribunal report last week disappointed those most eagerly awaiting it. Haemophiliacs and their next-of-kin, for whom the struggle for an inquiry has been a life-long one, feel dejected and bitter.
They had sought the truth. They had sought accountability for the "murder", as some described it, or death, of 79 people infected with HIV and hepatitis C through blood products administered for the treatment of haemophilia.
Instead, they got a report which was, at best, vague in apportioning blame; at worst, a whitewash - and a costly one at that. The current bill for the inquiry stands at €12.1 million, of which €4.2m went on the tribunal's legal team, and €2.9m on the tribunal's administration. Has it all been a waste of time and money?
To pose such a question seems an insult to the haemophiliac community, particularly the 64 people who testified at the inquiry, describing how their infection or that of a loved one had impacted on their lives. But it's a question some of those witnesses are asking themselves.
Ms Linda Dowling, whose father Joe died from AIDS after being infected through an imported blood product, said the tribunal had "missed the human element" of what happened. Because of the stigma of HIV and hepatitis C, most people chose to give evidence under pseudonyms, and as a result, she said: "I feel we let them [those responsible\] off the hook. If people had been able to put a face on what happened, they wouldn't have got off so easy."
Nine days on from publication, such feelings have strengthened. Today they will be aired at a meeting of the Irish Haemophilia Society (IHS), from which a collective response to Judge Lindsay's work will be forthcoming.
In evaluating that work, it's hard not to make comparisons with the 1997 Finlay Tribunal, which inquired into the infection of women with hepatitis C through Anti-D. That body sat for just two months, and reported within five weeks of finishing. In contrast, Lindsay took two years, and a further 10 months to report.
The greatest contrast, however, is in the content of the reports. While Finlay pinpointed a number of individuals to blame, Lindsay spoke little of wrongdoing. Yet, on the surface, both inquiries dealt with failings of a similar magnitude within the Blood Transfusion Service Board and the broader healthcare system.
Thus, one has to ask, which report was fairer, because it seems if Lindsay got it right, Finlay got it wrong, and vice versa?
The most disappointing aspect of the Lindsay report was that it left questions unanswered. This wasn't all Judge Lindsay's fault as arguably she was constrained by her terms of reference, particularly in investigating multinational pharmaceutical companies. But, in other respects, the chairwoman seemed unwilling to address the more difficult questions.
For instance, the conflict of interest of the late Mr Sean Hanratty, former BTSB senior technical officer, went unmentioned. Mr Hanratty was a founder shareholder in a company which imported products believed to have infected many haemophiliacs with HIV. He was also the BTSB official in control of key internal documents destroyed in 1993. But neither this incident, nor Mr Hanratty's role in product selection, were openly factored into Judge Lindsay's deliberations on the BTSB's actions.
In other areas, the chairwoman seemed like someone split between two minds. Adjudicating, for example, on the contradictory evidence of Prof Ernest Egan and Dr Terry Walsh on whether the former informed the latter in January 1996 of the infection with HIV of one of his patients through BTSB cryoprecipitate (cryo), Judge Lindsay said firmly he had. Yet, if this was the case, and Dr Walsh, former BTSB senior medical officer, was told of the infection, surely he had a duty to act, by ensuring all non-heat-treated BTSB product, which would guard against HIV, be recalled. In his own evidence, Dr Walsh said it would have been "all the more important" to have untreated stocks of Factor IX recalled had he known about the case. But all Judge Lindsay said was Dr Walsh "ought to have pursued the information".
There seemed to be an attempt to downplay the effect of decisions, or the lack of them. At the end of the same chapter, the chairwoman said "fortunately it does not seem that the failure of the BTSB" to take certain steps after May 1985 on cryo "resulted in the infection of any other person with haemophilia with HIV". This was true to the extent that no one else was infected through cryo. But had related actions been taken quicker some people could have avoided infection through BTSB Factor IX.
The report threw up other questions about the handling of the tribunal itself. In a section dealing with the BTSB's failure to follow up reports of infections, Judge Lindsay noted "on the tribunal's analysis, the board were not entirely blameless". But if this was the case, why weren't board members called to give evidence at the inquiry, as desired by the IHS?
In writing her report, the chairwoman seemed to have leant heavily on her legal team, especially Mr John Finlay SC, whose closing statement formed something of a framework for the final document.
One has to accept Judge Lindsay's job was not to provide a head on a plate. Nor was she there to counsel a traumatised community. Rather she had to adjudicate fairly on the issues. But, within that, the least haemophiliacs and their families deserved was that she would be unambiguous in her findings, and would openly assess evidence highlighted by the IHS, even if she chose then to reject it.
In failing to do so, Judge Lindsay has let down a long-suffering and betrayed community.