It was only a matter of good fortune that persons with haemophilia did not end up being infected by a product which the Blood Transfusion Service Board had failed to recall in 1986 after it discovered the method of viral inactivation used on it was not up to standard, the tribunal was told.
Minutes of a BTSB meeting held in July 1986 showed that one of its technical staff, Mr John Keating, had reported on an AIDS conference in Paris and stated that the minimum standard of heat-treatment now recommended for factor 9 blood-clotting agents was 60 degrees for 72 hours. It was agreed that this standard would be applied to existing stock of factor 9 at Pelican House.
Mr John Trainor SC, counsel for the Irish Haemophilia Society, said he was concerned that the board had this knowledge in its possession but did nothing to withdraw products heated to the old protocol. Dr Terry Walsh, who was a consultant haematologist at Pelican House at the time, said for 20 hours it believed them to be safe. when information came to hand about the newer type of heat-treatment it was used on all stock.