The recall of a batch of blood products on discovering a donor who contributed to it had tested HIV-positive was referred to as "a quality control problem" by the Blood Transfusion Service Board, the tribunal heard.
Dr Terry Walsh, former chief medical consultant of the BTSB, said there was a feeling both in the BTSB and the Department of Health that panic might ensue if knowledge of the possible contamination of the product became known.
He said he had been directed by the director of the BTSB in 1985, the late Dr Jack O'Riordan, to treat the issue with the utmost confidentiality. This was why the "quality control" euphemism was used.
The letter containing the euphemism was written by Dr Walsh, who at the time was a consultant haematologist, to Prof Ernest Egan, a consultant haematologist at University College Hospital, Galway, on December 23rd, 1985.
Counsel for the tribunal, Mr Gerard Durcan SC, put it to Dr Walsh that to refer to such a serious matter as a quality control problem was an understatement.
Dr Walsh said he believed Prof Egan knew what the problem was and that he would be able to find subsequent correspondence from him to bear this out. However, he was unable to say when Prof Egan became aware of the problem.
Counsel suggested that if Prof Egan had known, there would not have been a problem about putting it in the letter. Dr Walsh said there was no reason for him not to tell Prof Egan about the donor testing HIV-positive.
The tribunal heard that shortly after HIV testing of blood donations was started in October 1985 a person who had been donating for years to the pool from which anti-D was made tested HIV-positive.
Dr Walsh said this was a huge shock. He said hospitals were telephoned and batches of anti-D made from this person's blood were immediately recalled. There was no evidence that anybody receiving anti-D became infected with HIV.
Mr Durcan asked why this event did not immediately set off alarm bells in the BTSB and cause the board to recall its Factor 9 clotting agents as well.
Dr Walsh said as far as he knew this was not given consideration. He understood the Factor 9 product was under constant review.
Another new document opened yesterday showed that consideration was given at a meeting in Pelican House in November 1985 to "push cryo" rather than issue heat-treated products, which would be virally inactivated and pose a lesser risk to patients. Cryo was manufactured by the BTSB and used as a clotting agent before imported factor concentrates became available. It was not suitable for home treatment.
This meeting took place a year after the first haemophiliac was diagnosed with AIDS and some time after Prof Ian Temperley, former director of the National Haemophilia Treatment Centre, said he would not accept non-heat-treated products.
Notes of the meeting kept by the board's chief biochemist, Ms Cecily Cunningham, suggested that they would rescind a decision by Dr Helena Daly (a locum for Prof Temperley when he went on sabbatical in 1985) to use only heat-treated products and push cryo instead "for a while".
Counsel for the tribunal put it to Dr Walsh that the BTSB had large stocks of cryo on hand and wanted to have them used up. Dr Walsh said this would not be suggested at the expense of patient safety. "I'm totally gobsmacked by it to an extent if that was a serious consideration," he said.