Given the essential historical nature of its investigation, the Tribunal is reluctant to make detailed recommendations in regard to the operation of the Blood Transfusion Service or the arrangements for the treatment and care of persons with haemophilia at the present time. Notwithstanding such reluctance, the Tribunal believes that there are a number of matters in respect of which it can usefully make recommendations and these are as follows:
1The blood products supplied to persons with haemophilia should be of the highest standard and of the safest nature that are available. The Tribunal believes that this is the situation at present but this must continue to be the case.
2A Co-ordinating Committee in regard to the treatment and care of persons with haemophilia should be established with representatives from the various different organisations and interest groups in relation to haemophilia care. The Tribunal does not believe that it is appropriate for it to set out a detailed structure and composition of such a committee, rather this should be a subject of discussion and agreement between the various interested parties and the Minister for Health and Children. Its remit should include all aspects of the treatment and care of persons with haemophilia including choice of blood products to be given to such persons.
The Tribunal is of the view that it is essential that this Committee be properly resourced and have adequate personnel and office facilities available to it. Consideration should be given to whether it would be desirable to have the Committee established pursuant to Statute to ensure its efficient and effective operation.
3There should be greater co-operation and exchange of information among the various doctors who treat and care for persons with haemophilia. The Tribunal formed the impression that co-operation and exchange of information between the National Haemophilia Treatment Centre and Regional Centres and Hospitals caring for persons with haemophilia was and is somewhat haphazard. There should be a meeting at least once a year of doctors treating persons with haemophilia at which a doctor or doctors from the National Haemophilia Treatment Centre and each Regional Centre or Hospital where haemophilia care is provided should attend. This should hopefully ensure better co-ordination and more efficient exchange of information.
4A sufficient number of Consultant Haematologists should be appointed to posts throughout the country to provide adequately for persons with haemophilia and others who require haematology treatment. The Tribunal is satisfied that until recently the number of Consultant Haematology posts was grossly inadequate. It heard evidence of recent efforts to improve the situation. It is essential these should be pursued to a successful conclusion.
5Medical records should be kept and maintained in a more satisfactory manner. During the course of its work the Tribunal was struck by the unsatisfactory and incomplete nature of the medical records which were available in regard to particular patients. Of course, this may have been caused to some degree by the passage of time, but nonetheless record keeping seems to have been uneven and incomplete. It may well be that the greater use of computer records has already brought about improvements in this area.
6Complete and accurate statistical records should be maintained by the National Haemophilia Treatment Centre in regard to the level and type of infection experienced by persons with haemophilia in this country. Again the Tribunal found it difficult, despite the best efforts of the Virus Reference Laboratory, to obtain a full and complete picture of the true level of infection of persons with haemophilia, in particular in regard to the level of infection with hepatitis C. It seems to the Tribunal that such national records should be maintained by the National Haemophilia Treatment Centre and should be readily available as may be required.
7Doctors should ensure that test results in relation to patients are given to them as soon as such results become available, unless there is a compelling medical reason to the contrary. Also if such results are such as to be likely to cause distress and upset to the patient he or she should be referred on to the appropriate agency in the hospital or unit for appropriate advice and counselling. A recurring theme in the Tribunal was the upset and distress which can be caused by delay in obtaining such results and by the absence of appropriate counselling and further advice.
8The Irish Blood Transfusion Service should establish protocols to ensure that if in the future new tests become available for infective agents in blood or blood products, a positive result of any such test is communicated to the relevant donor as soon as possible and he or she is referred for appropriate counselling and further advice. Such protocols should also ensure that the necessary look back procedures are carried out arising from a positive test result in regard to such an infective agent.
The Tribunal has considered the submission made to it that it should forward a copy of its Report to the Director of Public Prosecutions. It is not the function of a Tribunal of Inquiry to decide issues of criminal or civil liability. The Tribunal is of the view that it is not appropriate in these circumstances to send a copy of the Report to the Director.
The Tribunal is aware that since the completion of its public hearings the Minister for Health and Children has commissioned and obtained a report from Mr. Paul Gardiner SC in regard to the possibility and viability of the holding of a further Inquiry into the role of the international drug companies in relation to the infection of persons with haemophilia in this country. In these circumstances, the Tribunal does not believe that it would be appropriate for it to make any comment in relation to the possibility of a future Tribunal of Inquiry since the Minister has sought and obtained a detailed report in regard to that very question.
Further, the Tribunal is aware that the Minister for Health and Children and the Irish Haemophilia Society have reached agreement in regard to the payment of compensation to persons with haemophilia who were infected with HIV. The arrangements for the payment of such compensation are contained in the Hepatitis C Compensation Tribunal (Amendment) Act 2002. The Tribunal, therefore, believes that it is not necessary or appropriate for it to make any recommendation in regard to the question of compensation for such persons.