THE victims of the hepatitis C scandal received an apology yesterday from counsel for the Blood Transfusion Service Board (BTSB) for what were described as its negligence, repeated wrong decisions and breach of protocols.
Mr Paul Gallagher SC said nothing could undo the wrong, but the words of an apology were the beginning of an expression of sorrow and regret. The follow-up was to try to match that with the actions of the BTSB in confronting the crisis.
He said that now one looked at the mistakes and asked how doctors and an organisation "devoted to doing good" could repeatedly make wrong decisions. "I am not sure if that can ever be fully explained," he said.
He referred to the testimony of Dr Terry Walsh, the former chief medical consultant at the BTSB, who had said there was an unjustified complacency, an unjustified belief in the safety of anti-D and an unwillingness to confront the evidence. He had said that perhaps there was a failure to have a person whose duty would be to fully investigate such matters. There had been a misreading of results when products were tested.
"It is not an excuse or justification, but I put it forward mainly as an explanation, but an explanation for what was fundamentally wrong and an explanation for a complete failure to address the issues," he said.
Mr Gallagher said he wanted to express the BTSB's "very, very profound and deep upset and regret at the terrible tragedy that has befallen not only the women who received the anti-D, but the people who received subsequent donations".
He said that although he was addressing the chairman, Mr Thomas Finlay, he was directing the apology at those who had suffered.
"I do not think words are adequate to express the level of regret and sorrow, and I accept that, but nevertheless I believe that the beginning is to express it in words, and I think the follow-up is to try and match it with actions, which, I hope, has been done," he said.
The real lesson to be learnt was one which would hopefully prevent it or anything like it occurring again.
The actions of the blood board since 1994 were to provide help to the victims and to relieve the suffering. It was a public service that failed "lamentably" in 1976/77 and, to a lesser extent, in 1991.
Changes in personnel and management structure since 1994 were not just to fulfil its service, but also a manifestation of its sorrow "and desire that such a tragedy will not occur again". It had had to admit and accept that "the confident belief" in its knowledge and systems had been misplaced.
"The BTSB has had to confront itself like no other State body has had to do in the history of the State ... it has had to confront itself by attempting to ensure that its products would henceforth be as safe as they could possibly be, and that the human error, the misjudgment and the complacency, all of which contributed to this terrible tragedy, would not and could not occur again."
Perhaps organisations did become complacent, he said, when they were regarded as the experts in the country.
The measures put in place were not a matter of pride and satisfaction, but "a realistic attempt to address what was wrong". The implementation of "the significant part" of the Bain consultants' report was also something to be taken into the overall context.
"We have not sought in this tribunal to blame anyone else, and even those centrally involved, and particularly Dr Walsh, gave his evidence in a way which did not seek to blame anyone else, in a manner which did not seek to involve anyone else in his decisions," he said.