THROUGH the tangled wed of dates, times, patients, doctors, decisions and lack of action, one date stood out at the first day of evidence of the hepatitis C Tribunal. It was November 5th, 1977. That was day that Mrs Brigid McCole received the dose of antiD that ultimately led to her death.
Mrs McCole, who died in October, received batch No 250 of anti D. It included infected plasma from the woman known as patient X. Mrs McCole's counsel, Mr John Rogers SC, and counsel for the Tribunal, Mr James Nugent SC, told how the BTSB ignored the dangers, although they knew there was a serious problem.
The tribunal is expected to continue for up to three months.
Mr Nugent appeared to concentrate responsibility on a small number of individuals within the BTSB, but Mr Rogers, also representing Positive Action, said it was known at "a number of levels" within the organisation.
Exactly what occurred from 1976 to 1996 was explained chronologically, with missing bits filled in and new information added. One was the way in which the hepatitis C scandal finally came to light. Mr Nugent explained that in December 1991 Dr Terry Walsh received results from Middlesex Hospital in London indicating that patient X had been hepatitis C positive and that samples frozen in 1976 were infected.
In January 1992 Dr Walsh wrote back to the hospital and said he was gathering more information. He showed the letter to Dr Emer Lawlor, consultant haematologist at the BTSB. She realised the contents had significant implications and she believed Dr Walsh would "take the necessary steps". He also spoke to Ms Cecily Cunningham, principal biochemist with the BTSB, and asked her for additional information.
"She remembers that she replied within a day of the request. She did mention it to Dr Walsh subsequently and got an abrupt response." Dr Walsh never got back to Middlesex Hospital and "nothing further was done and it was not reported to the board" of the BTSB. "None of this story emerged to the board until January 1994."
It was then that Dr Joan Power, a consultant haematologist with the BTSB in Cork, discovered a high number of rhesus negative mothers with the virus. In October 1991 she began organising for all potential donors to be tested for hepatitis.
In January 1994, when she spoken to Dr Walsh about this he was visibly shaken", Mr Nugent said. After that there was a "very peculiar" telephone call from Dr Walsh to Dr Eamonn McGuinness, patient X's consultant gynaecologist, Mr Nugent said.
"The question of patient X came up and Dr McGuinness said to Dr Walsh `but you know she had jaundice'. Dr Walsh said he did not. Dr McGuinness said he himself had told him she had developed hepatitis C. He told him it was so serious they should go down to the Department and tell the Minister for Health this minute and tell the story.
"Dr Walsh said that would not be necessary. But he telephoned him that night and said he did accept that she had hepatitis."