THE tribunal report found that between 1975 and 1994, "successive Ministers for Health and the Department of Health" had failed to provide enough resources to the National Drug Advisory Board (NDAB) to enable it to carry out the licensing and authorisation of products made at the BTSB.
It also found that if the resources had been provided it was possible recipients' reactions to the contaminated anti-D in 1976 and 1977 would have been revealed. It further concluded that "the persons involved in the BTSB would have made further investigations than they did if they were aware of the likelihood of further inspections and interrogation".
In the report's view, the Minister (for Health) and the Department had "complete control over the personnel and composition" of the NDAB and its functions, as well as the staff and other resources it needed to carry out its role.
There was "ample evidence" presented to the tribunal, it said, indicating that the levels of staff at the NDAB, particularly in the technical/laboratory area, "was quite inadequate at all times from 1975 onwards". This was the case "in both the medical and pharmaceutical fields
It also said it was "quite clear" this situation "was consistently made known to the Department of Health" in the relevant years. "Urgent" applications (for more resources) had been made during "very large parts" of the period concerned by "distinguished voluntary chairmen" of the NDAB, who were concerned about "the absolute necessity" for more technical staff.
At times, the problem in recruiting centred on the refusal by the Department to sanction it. However, at other times the problem was that though the Department agreed to sanction recruitment, it offered salaries "which clearly failed to attract persons who were considered competent to carry out the tasks".
The tribunal felt that whereas inspections of the BTSB by the NDAB may not have uncovered details about the use of patient X's plasma, "except by some form of chance", they could have uncovered information concerning the reaction of anti-D recipients from the 1976-1977 period.
It "certainly" would appear likely, it concluded, if all those involved with the patient X case were aware they would "on a regular basis" face questioning from an NDAB inspector, "they might have been less content to make the decisions and avoid the making of further investigations as they did".
To that extent, "but to that extent only", the report concluded that the Department's failure to supervise the NDAB "with regard to these matters" and the consequential failure of the NDAB to properly carry out its duties of inspection and assessment in the context, had "contributed to the infection of anti-D with hepatitis
