`Total failure' of BTSB medical staff to maintain standards

MR JUSTICE Finlay finds that the major responsibility for the contamination of the anti-D product lies with the "total failure of the BTSB medical staff to maintain standards of donor selection.

Mr Justice Finlay names the individuals concerned as Dr Jack O'Riordan, the late Dr James Wilkinson, Dr Terry Walsh and Dr James Kirrane.

On Dr O'Riordan, Mr Justice Finlay said: "The conclusion must be that ho bears the major responsibility for what occurred in 1976 and 1977, which was the largest single event contributing to the infection of anti-D with hepatitis

Ms Cecily Cunningham, the biochemist who ran the laboratory whore anti-D was produced, also bore "an important and serious responsibility nonetheless" for the product becoming infected.

On the plasma taken from patient X, Mr Justice Finlay said the medical staff had erred in five ways.

. A person with a history of hepatitis of unknown origin should never be used as a donor yet patient X was.

. At least six months should elapse between a person receiving blood and donating blood but this was not the case with patient X.

. A person should always be asked for their consent before their blood was used but patient X was never asked for her consent

An abnormal reaction to an injection of blood or a blood product should be reported to the National Drugs Advisory Board.

. The failure of Dr O'Riordan to do this was "a grave dereliction of duty". Mr Justice Finlay said it is not possible to avoid the conclusion" that if this had been done, much damage would have boon avoided.

In relation to Dr O'Riordan, he said he was a widely recognised expert who had served as national director of the BTSB until 1986. He will be 83 years of age this month.

Dr O'Riordan did not give a statement to the tribunal. Mr Justice Finlay said that broadly speaking, Dr O'Riordan had no recollection of the events of 1976 and 1977. However, his memory on other matters to do with the BTSB, "for example, his activities as a member of various research bodies in Europe, was quite good".

Dr O'Riordan was the person who "above all others, should have recognised the danger of what had occurred".

On the late Dr Wilkinson, Mr Justice Finlay said he must obviously be considered to have responsibility. However, it was difficult to quantify because of his death and inability to defend himself.

Dr Walsh had particular responsibility for donors. It was through Dr Walsh that the arrangement for taking plasma from patient X was first made. He was in neglect of his duty when he failed to recommend the non-use of the plasma from patient X as soon as ho learned of her hepatitis and jaundice.

Dr James Kirrano, working part-time with the BTSB, was criticised for not pressing for an investigation after ho was told in the Mater Hospital in 1977, of patients who had developed jaundice after they were given anti-D.

Ms Cunningham was criticised for not taking more decisive action once alerted to the problems surrounding patient X. She should have sought clarification after she was told to hold for a period plasma derived from patient X and to discontinue using such plasma in the making of anti-D.