1991 test showing contamination of BTSB's anti D in 1977 not acted on


A CONSULTANT haematologist at the BTSB has expressed regret that she failed to further discuss a 1991 report which indicated that anti D produced by Pelican House in 1976 was contaminated by the hepatitis C virus.

Dr Emer Lawlor told the tribunal on Tuesday that she failed to raise the matter again with Dr Terry Walsh, then chief medical consultant at the BTSB. She recalled going to his office in December 1991 to discuss a fax from Dr Carson of the Middlesex hospital in London, who pointed out that he had noted a problem with the anti D product sent to it for testing by the BTSB in 1977.

The frozen batches were examined after new testing methods were developed. The fax noted the anti D was contaminated by the hepatitis C virus.

Dr Lawlor said hepatitis C was "a silent disease". Therefore it was likely that more women than those identified with hepatitis like symptoms after receiving the batch in 1977 were infected.

At the time she appreciated there was a problem, but subsequently forgot all about it. .. it just slipped my memory. He never came back to me. It is something I deeply regret," she said.

She was very busy, she said one of her children was very ill over Christmas, and she was attending meetings and teaching.

She agreed that when "the balloon went up" in 1994, she realised what a problem there was.

Later in her testimony she said that if that fax had been acted upon, about 30 people with anti-D related liver infections would now be clear.

She said that 43 women out of a total of 12,000 screened for hepatitis C became infected through anti-D manufactured using patient Y's plasma.

Following the introduction of screening, a donor who was found to have a history of drug abuse tested positive for hepatitis C He had donated a number of times. "In spite of our leaflets people still donate if they are no longer abusing drugs", she said. She agreed that patient Y became infected from that donor's plasma.

Completing her evidence to the inquiry on Tuesday, Ms Cecily Cunningham, principal biochemist at the BTSB, said a stock of non heat treated Factor 9 blood product, for haemophilia, continued to be distributed in 1985 after this new anti HIV heat treatment was introduced.

She said Mr Hanratty, the chief technical officer, and the medical consultants were in charge of haemophila products. "It was not my function to advise on coagulation factors." At the time she did not have the information that the international standard for Factor 9 was to be treated for 72 hours at 68 Celsius. She just carried out instructions on such matters and had not been delegated to attend international meetings. Mr Hanratty attended those.

She felt the anti D manufacturing unit, of which she was in charge, was being marginalised, and made a number of complaints, in the mid to late 1980s. She stated her position in writing in June 1991, complaining about lack of resources.