The tribunal made the following recommendations:
1. The blood products supplied to persons with haemophilia should be of the highest standard and of the safest nature that are available.
The Tribunal believes that this is the situation at present but this must continue to be the case.
2. A Co-ordinating Committee in regard to the treatment and care of persons with haemophilia should be established with representatives from the various different organisations and interest groups in relation to haemophilia care.
The tribunal does not believe that it is appropriate for it to set out a detailed structure and composition of such a committee, rather this should be a subject of discussion and agreement between the various interested parties and the Minister for Health and Children. Its remit should include all aspects of the treatment and care of persons with haemophilia including choice of blood products to be given to such persons.
The tribunal is of the view that it is essential that this committee be properly resourced and have adequate personnel and office facilities available to it.
Consideration should be given to whether it would be desirable to have the committee established pursuant to statute to ensure its efficient and effective operation.
3. There should be greater co-operation and exchange of information among the various doctors who treat and care for persons with haemophilia.
The tribunal formed the impression that co-operation and exchange of information between the National Haemophilia Treatment Centre and Regional Centres and Hospitals caring for persons with haemophilia was and is somewhat haphazard.
There should be a meeting at least once a year of doctors treating persons with haemophilia at which a doctor or doctors from the National Haemophilia Treatment Centre and each Regional Centre or Hospital where haemophilia care is provided should attend.
This should hopefully ensure better co-ordination and more efficient exchange of information.
4. A sufficient number of consultant haematologists should be appointed to posts throughout the country to provide adequately for persons with haemophilia and others who require haematology treatment.
The tribunal is satisfied that until recently the number of consultant haematology posts was grossly inadequate.
It heard evidence of recent efforts to improve the situation. It is essential these should be pursued to a successful conclusion.
5. Medical records should be kept and maintained in a more satisfactory manner.
During the course of its work the tribunal was struck by the unsatisfactory and incomplete nature of the medical records which were available in regard to particular patients.
Of course, this may have been caused to some degree by the passage of time, but nonetheless record keeping seems to have been uneven and incomplete.
It may well be that the greater use of computer records has already brought about improvements in this area.
6. Complete and accurate statistical records should be maintained by the National Haemophilia Treatment Centre in regard to the level and type of infection experienced by persons with haemophilia in this country.
Again the tribunal found it difficult, despite the best efforts of the Virus Reference Laboratory, to obtain a full and complete picture of the true level of infection of persons with haemophilia, in particular in regard to the level of infection with hepatitis C. It seems to the tribunal that such national records should be maintained by the National Haemophilia Treatment Centre and should be readily available as may be required.
7. Doctors should ensure that test results in relation to patients are given to them as soon as such results become available, unless there is a compelling medical reason to the contrary.
Also if such results are such as to be likely to cause distress and upset to the patient he or she should be referred on to the appropriate agency in the hospital or unit for appropriate advice and counselling.
A recurring theme in the tribunal was the upset and distress which can be caused by delay in obtaining such results and by the absence of appropriate counselling and further advice.
8. The Irish Blood Transfusion Service should establish protocols to ensure that if in the future new tests become available for infective agents in blood or blood products, a positive result of any such test is communicated to the relevant donor as soon as possible and he or she is referred for appropriate counselling and further advice.
Such protocols should also ensure that the necessary look back procedures are carried out arising from a positive test result in regard to such an infective agent.