Anatomy of a catastrophe

The publication yesterday of the report of the Tribunal of Inquiry into the infection with HIV and Hepatitis C of persons with…

The publication yesterday of the report of the Tribunal of Inquiry into the infection with HIV and Hepatitis C of persons with haemophilia is most welcome. Judge Alison Lindsay has produced a detailed and comprehensive report and she and her team are to be congratulated for the professionalism with which they carried out their task.

The tribunal heard evidence from almost 150 witnesses, many of whom gave personal testimony about the impact of the infections on them and their families. As the report notes: "Their evidence was at times sad, at times tragic and at times harrowing." Clearly a most valuable function of the inquiry has been to provide a forum in which the victims could finally be heard.

Given that the matters investigated by Judge Lindsay relate to events which occurred up to 25 years ago, it has been difficult for the tribunal to reach clear-cut answers to the issues it examined. For example, the report states, in reference to the 104 haemophiliacs who contracted HIV infection: "It is impossible to form a fixed and certain view as to which particular product caused a particular infection." Again, when considering the 217 people infected with Hepatitis C, the tribunal was unable to identify the particular product responsible for individual infections.

The Blood Transfusion Service Board (BTSB) is criticised over its handling of specific issues. Among those was its failure to react speedily to international knowledge and events, such as a crucial publication by the US Centre for Disease Control which may have changed its practices and protocols. Its role as a distributor of commercial products is criticised, in particular its failure to draw the attention of treating doctors to the risk of hepatitis from commercial concentrates.

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The tribunal makes a number of welcome recommendations in regard to the ongoing operation of blood transfusion services and arrangements for the treatment of people with haemophilia. It suggests the establishment of a coordinating committee with representatives from the different interest groups involved in haemophilia care. The report calls for greater co-operation and exchange of information among various doctors who treat people with haemophilia. It identifies the need for more consultant haematologists to be appointed throughout the State and calls for medical records to be kept and maintained in a more satisfactory manner. It states that doctors should ensure test results in relation to patients are given to them as soon as they are available.

The Lindsay Tribunal Report is exact in its analysis of past events which have led to 78 deaths to date and tragedy for so many other individuals and families in the State. It must be read and considered carefully by all who have an interest in healthcare. Past mistakes must be noted and learnt from so that the catastrophe which afflicted a vulnerable group of our citizens is never again repeated.