MORE than 70 witnesses gave evidence to the Hepatitis C Tribunal of Inquiry. At the conclusion it was possible to state almost exactly how the infection of anti-D immunoglobulin occurred.
However, the burning questions which remained on most lips was why such an unspeakable thing could have been allowed to happen in the first place, and how it went unchecked for over two decades.
"It remains," says Mr Justice Thomas Finlay in his report, "to attempt to answer the obvious question as to why all these things occurred".
But none of the Blood Transfusion Service Board employees who gave evidence was able to offer any real form of explanation as to why the events happened.
It appears the establishment of a unit for the production of anti-D in 1970, made exclusively from the plasma of Irish voluntary donors, in sufficient quantities to meet the needs of the community was "a particularly noteworthy and splendid" achievement, of which Dr Jack O'Riordan (former National Director) and his colleagues were "justly and understandably proud."
For this supply of home produced anti-D to fall short of requirements at any time, and to be replaced by imported products, would have been a major admission of failure.
Instead they just continued with the manufacture of the product. They took plasma from an infected woman, Patient X, who had no knowledge it was being used, and had herself been infected by an earlier transfusion from the BTSB.
The nearest any of the evidence went to an explanation was an answer given by Dr Terry Walsh, former chief medical director of the BTSB. It appears the board. .would prefer to believe that the women's infection in 1976 was infectious hepatitis "rather than a product related problem".
So rather than make any admission, it instead, in the words of Ms Cecily Cunningham, chief biochemist, "ploughed on" with the manufacturing. Its pride resulted in the infection of 1,600 people, including Mrs Brigid McCole, who died a painful death last October
It appears that in 1991, when the letter from the Middlesex Hospital that Patient X's plasma was hepatitis C positive was sent to Dr Terry Walsh, he had a "vague hope", "that by ignoring the problem it would go away". Ms Cunningham was also held partly to blame for this "completely and inadequate and non-existent" response.
The report names names by identifying those responsible for the failure that occurred in the BTSB during those years - to a major extent" Dr Jack O'Riordan, Dr Terry Walsh, and Dr James Kirrane, a part-time consultant with the BTSB who must bear some responsibility for not insisting on a greater investigation of the reaction of patients to the anti-D, and Ms Cunningham who "must also bear a responsibility".
It found that "wrongful acts" were committed and they were not only unable to face up to the consequences of those acts but also refused to face the consequences of what had been done in relation to Patient X.
Moving forward to the 1990s, the report addresses one of the repeated complaints of the infected women which was that they were counselled by the people who were responsible for their infection. Upon presenting themselves at Pelican House they had been questioned about whether they had ever had a tattoo, used drugs intravenously, who their sexual partners were and where they had had their ears pierced.
The report found that the reaction of the BTSB to the complaints about counselling was "inadequate" that it should have, sought assistance from the medical profession and created independent counselling earlier than late 1994. The board was "somewhat inadequate" in its reaction:
to the problems of testing, informing and counselling people "by reasons of insensitivity".
Mr Justice Finlay was also critical of the board's decision not to circulate a letter from Positive Action seeking contact with other victims of hepatitis C. Moving away from the BTSB, the report criticised the failure of the National Drugs Advisory Board for failing to make annual inspections at the BTSB and carrying out its function in advising on the granting of a manufacturing licence for anti-D.
However, it said that as a matter of law, anti-D was not a therapeutic substance under relevant, legislation. A manufacturer's licence under the Substances Act "would not have been appropriate because it would have been of no legal effect".
Turning his attention to the role of politicians, Mr Justice Finlay said that between 1975 and 1994 successive ministers for health" and the Department of Health "failed adequately and appropriately to supervise the NDAB". If those resources had been provided, it is possible the reactions of the women who received contaminated anti-D in 1976 and 1977 would have been revealed and that those involved in the BTSB would have made further investigations than they did if they knew there would be "further inspections and interrogations".
The present Minister, Mr Noonan, only comes under fire for the delay - from the end of September 1995 to September 1996 - in the introduction of the Act which was to provide for the long-term provision of treatment, counselling and care of hepatitis C victims.
His predecessor, Mr Brendan Howlin, receives a few raps on the knuckles but his decision to set up an Expert Group instead of an inquiry was seen as "an adequate and appropriate reaction to the facts as they were then".
Mr Noonan was not criticised either for not setting up the tribunal in March 1996 after a report containing the words "infective hepatitis" was made public. It was an adequate reaction to the facts as they were then, said Mr Justice Finlay.
The report said it seems clear that the administrative side of the Department must bear the major responsibility for the delay in introducing hepatitis C screening in October 1991, which appears to have "been unnecessary and unwise". Dr Niall Tierney, chief medical officer of the Department must bear some responsibility for so much of the delay in the introduction of the screening. In this instance the BTSB "adequately pressed" for the screening.