THE report of the hepatitis C tribunal, which the Government has referred to the Director of Public Prosecutions, contains startling and severe criticism of named officials of the Blood Transfusion Service Board.
The report, written by the tribunal chairman, Mr Justice Thomas Finlay, uses unprecedentedly strong language against a number of BTSB employees including:
. Dr James O'Riordan (83) bears the major responsibility for the infection of anti-D which occurred in 1976/1977.
. Mrs Cecily Cunningham, the BTSB's principal biochemist who ran the laboratory where anti-D 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".
. Dr Terry Walsh, though at the time of the 1976 infection the most junior of the BTSB's three medical officers, had particular responsibility for donors. He was in neglect of his duty when he failed to recommend against using Patient X's plasma as soon as he learned of her hepatitis and jaundice. When he received a letter in 1991 confirming Patient X's plasma was hepatitis C positive, his response was to do nothing and he appeared to have "a vague hope that by ignoring the problem it would go away".
. Dr James Kirrane, a part-time consultant with the BTSB, is criticised for not pressing for an investigation after he was told in the Mater Hospital in 1977 of patients who had developed jaundice following their being given anti-D.
Of those named only Mrs Cunningham is still employed by the BTSB. She is currently on sick leave.
A Government source said last night that it was now up to the DPP, Mr Eamonn Barnes, to decide if the conduct disclosed in the report amounted to "evidence of criminality" or a degree of wrongdoing that was a matter for civil litigation only.
"It is an unusual step but the particularly tragic circumstances meant that there was no uncertainty on this issue," said a Government source.
"This was a great tragedy where a whole lot of people were affected, where the damage could not be undone and where uncertainty contributed to the pain. Because of this, it was felt important that the report should not simply be left lie."
A prominent senior counsel said last night that the DPP could order a prosecution for criminal negligence. A charge of manslaughter or assault would also be open.
However, another legal source said a prosecution against the BTSB, any former employees or any Department of Health officials was unlikely. "There is no culture in this country of people being brought to book for this kind of thing," he said.
Yesterday the Minister for Health, Mr Noonan, said the results of the Investigation "into one of the worst public health scandals in the history of the State" had been sent to the DPP.
He said the Government accepted all the recommendations of the report.
More than £20 million will be allocated for the principal one which recommends the transfer of the BTSB headquarters from Mespil Road to St James's Hospital, Dublin, and the refurbishment of the blood bank premises in Cork.
"They thought it was the appropriate thing to do and they are not making any judgmental statement because it is for the DPP to decide matters regarding prosecutions," the Minister said
The report recommends a blood consumer council be set up, to maintain public confidence in the supply of blood and blood products. It calls on the Irish Medicines Board (IMB) to carry out two full inspections of the BTSB a year, and a report of these inspections is to be sent to the Minister for Health. A statutory procedure for the reporting of any abnormal reactions to blood or blood products received should be formulated by the IMB.
A standard operating procedure should be put in place by the BTSB for the recall of any product. Arrangements should be put in place which would permit the immediate replacement of blood supplies in the event of the entire stock of the BTSB of any particular blood product becoming defective.
Positive Action, the group representing the women infected through anti-D immunoglobulin, said it had received only a single copy of the report yesterday.