The report of the Tribunal of Inquiry into the Blood Transfusion Service Board and the contamination of anti-D products with the hepatitis C virus contains no surprises for those who followed the extensive media reportage of the tribunal's three-month hearings. Those who asked that the facts of the case be made clear, and be made public, should be well satisfied with the expeditious work of Mr Justice Finlay and his tribunal staff. Those who sought vengeance will be less happy. Those who seek just retribution must await the response of the Director of Public Prosecutions to the Government's proper decision that the Finlay report be forwarded to that office by the Minister for Health.
Those whose concern was to ensure the future safety of the blood supply will be glad that all of the tribunal's recommendations have been accepted by the Government. They will, however, delay final judgment until the various recommendations have been fully implemented, especially those which charge the Department of Health and the Medicines Board with more effective surveillance of the structures, processes and practices of the Blood Transfusion Service Board. They must also hope that the responsibility for this surveillance will be more effectively discharged than was the case during this worst public health scandal in the history of the State, and that the additional resources which the Medicines Board will require to discharge its technical duties will be provided by the Government.
This has been a costly scandal, not least in the apprehension, misery, illness and death that have been visited in varying degrees on somewhere between 1,000 and 2,000 women whose only desire was to protect their foetuses from the damage that could be inflicted by incompatible blood groups in the family. The cost of the inquiry itself, given the quality and extent of the information revealed, has been a mere £1 million or so. But the amounts paid out by that other inquiry the Compensation Tribunal already amount to something in excess of £30 million, and only one fifth of the cases before it have been heard and decided. The provision of further necessary resources to both the Medicines Board and the Blood Transfusion Service Board (particularly to relocate that board's main premises to the campus of St James's Hospital) will not come cheap but will likely be welcomed by the taxpayers.
Meanwhile, the words of Mr Justice Finlay's report, in their measured moderation, make chillingly compulsive reading. They contain echoes of the substance of such fictional horror thrillers as might have emanated from the pen of Robin Cook. Yet they are unable fully to explain why the facts of this tragedy occurred; why a once widely admired and wholly trusted health care service crumbled into a condition of denial in which even its own most basic rules of care and safety were disregarded. Was it pride in its earlier standards and reputation which caused its later fall from grace? The report's litany of "wrongful acts", "failures" and "inadequacies" makes sorry reading.
But the report itself must do a great deal to vindicate the effectiveness of the mechanism of a tribunal to elicit and elucidate facts in a reliable and cost-effective manner. The public's faith in tribunals has never been the same since the grossly expensive and ultimately arguable findings of the beef tribunal. The work of Mr Justice Finlay and his team must go some considerable distance towards restoring faith in the process, and should give some reassurance to those who are about to become involved in the next tribunal to examine the blood bank, this time in respect of contamination of the blood supply by the Human Immunodeficiency Virus.