The news which filtered through to the Blood Transfusion Service Board in mid-1986 that five or six haemophilia B patients had tested positive for HIV could not have been more shattering.
Numerous other haemophiliacs, namely those with haemophilia A, had already tested positive for the virus but their infections had been linked to imported clotting agents.
The haemophilia B cases, in contrast, were the first to be blamed on a product which was made at Pelican House.
Given the significance of the matter, not just from a public safety point of view but because of its litigation implications, one would have expected lengthy talks on the issue being recorded in the minutes of BTSB board meetings. Yet none can be found.
As counsel for the tribunal, Mr John Finlay SC, noted yesterday, the only trace of the issue was a handful of "coded" or "coy" references to the infectious product, Factor 9.
Was it possible somebody tried to cover up the discovery? More specifically, asked Mr Finlay yesterday, was it possible the board of the BTSB - the agency's decision-making branch - was never informed?
Former BTSB chief executive Mr Ted Keyes, on his first day giving evidence, emphatically denied the latter was the case. He said he was "certain" the board was told about the infections, if not during a board meeting then "off-board".
But, in an apparent contradiction to his evidence, Mr Keyes said he himself did not inform the board but rather it was a matter for Dr Vincent Barry, the Cork-based former chief medical consultant. Asked whether he believed Dr Barry told the board, Mr Keyes replied: "I don't think so."
Whether or not the board was informed, it appears the issue was handled within the blood bank with the utmost discretion.
The tribunal has already heard of the agency's concern about negative publicity arising from positive HIV tests and the possible impact on blood supplies.
Giving evidence at a previous sitting, Dr Terry Walsh, the BTSB's former chief medical consultant, accepted that an interview which he gave to a newspaper in January 1987 gave no indication of the positive haemophilia B tests (which rose to seven in all). The article had stated there had been "no new cases of AIDS antibodies showing up in Irish haemophiliacs" since 1985. This was "a very inaccurate picture", conceded Dr Walsh, who was one of a number of people interviewed for the piece.
On the separate issue of the recall of an anti-D product in December 1985, Dr Walsh said there was a feeling within both the BTSB and the Department of Health that panic might have ensued if the public had become aware of the product's possible contamination with HIV. He had been explaining why he had referred to the HIV scare as "a quality control problem" in a letter to the Galway-based haemophilia treater, Prof Ernest Egan.
As the tribunal hears more of these "guarded" references to HIV - as Mr Finlay described them yesterday - more weight is lent to the theory that the BTSB may have sought to cover up the source of the infections for fear of being sued.