THE principal biochemist at the BTSB, the Blood Transfusion Service Board, should no longer be employed in transfusion medicine, counsel for Positive Action told the tribunal of inquiry yesterday.
Mr John Rogers SC, who is also counsel for the McCole family, said that there had been "life threatening" breaches of BTSB procedures by Ms Cecily Cunningham when she was in charge of the anti D manufacturing unit, which operated at Pelican House from 1970 to 1994.
He told the tribunal chairman, Mr Justice Finlay, that there had to be accountability for the death of Mrs Brigid McCole, and the circumstances surrounding the infection of anti D immunoglobulin in 1977 and 1991 should be referred to the DPP, as one of the tribunal's recommendations.
Tracing the history of the scandal, he said that the former medical director of the BTSB, Dr Jack O'Riordan, had ignored one of his functions by failing to report to the BTSB board that the Rotunda Hospital had notified him of three anti D patients with hepatitis like symptoms in July 1977.
Taking all the factors into account, there seemed to have been a clear appreciation that the BTSB was dealing with non A, non B hepatitis. "On behalf of the McCole family, I say that Mrs McCole died as a result of these events. Now there must be accountability for this, sir, and I submit to you that one of your recommendations should be that the matter be passed to the Director of Public Prosecutions for investigation and direction."
He claimed that Ms Cunningham had been responsible for "significant and life threatening breaches of the standard procedures", adding: "I submit to you that you recommend that she not continue to be employed in transfusion medicine."
For his clients, the tribunal had become synonymous with the truth about their plight. They had found that what was considered a mistake was "a wrong". There was no test for hepatitis C in 1977 and his clients had been led to believe that the virus had got into the anti D "unbeknownst to the BTSB".
The BTSB had made a submission to the expert group that there was "a robust confidence in the manufacturing process as a means of excluding the virus", he said. But the BTSB was "reckless" in breaking its rules and in ignoring the warning signs. It was his clients' view that the tribunal should not shirk from finding facts and linking names and institutions expressly to those facts.
It was clear that Dr O'Riordan had known of the clinical diagnosis of Patient X having infective hepatitis in 1976.
Mr Rogers said that evidence had been heard from a member of the McCole family of the horrible effects of hepatitis C on Brigid MCole. "It would appear that up to the point of her death, none of the State institutions had come to appreciate that hepatitis C was a killer virus," he said.
The BTSB had ignored its guidelines that women, during pregnancy, "should not be used as donors". They also forbade donations from multiple or repeatedly transfused women. There had been a basic breach of transfusion medicine principles. "They were programmatically breaking this rule," he said.
The Department of Health had adopted a "non disclosure policy" after the scandal broke in February 1994 and there had been no "continuum of supervision". Officials had failed to ensure that the Minister for Health could report fully to government.
Mr Rogers said it should be a legal requirement for doctors to report patient reactions to medical products, particularly blood products, to the Irish Medicines Board. The responsibilities of BTSB staff should be delineated and the Department of Health's overseeing role should be defined.
There should be a "positive duty" on public servants to provide accurate and factual information to all victims in such a crisis, he added.