Lindsay Tribunal Report: Motion.

Mr. Glynn

I move:

That Seanad Éireann:

– notes the publication of the Report of the Tribunal of Inquiry into the infection with HIV and Hepatitis C of persons with haemophilia, and related matters and acknowledges the gravity of its findings;

– accepts in full the findings in the report;

– acknowledges the extraordinary suffering endured by those persons with haemophilia who were infected, and by their families, and acknowledges the harrowing personal testimonies given to the tribunal of inquiry by some of those who have suffered;

– notes and acknowledges the widespread sense of public dismay at the matters disclosed in the report;

– supports the Government decision to refer the report to the Director of Public Prosecutions;

– supports the Government's commitment to implement the recommendations in the report, and specifically to appoint a national haemophilia co-ordinating committee, and appropriate subcommittees, on a statutory basis;

– acknowledges the high standard of care currently being provided to persons with haemophilia and supports the Government's undertaking to work in partnership with the Irish Haemophilia Society and treating clinicians to ensure that the highest standards of health care continue to be made available;

– supports the Government's commitment to ensuring the availability of an adequate and ongoing supply of clotting factor concentrates that meet the highest national and international standards of safety and efficacy.

There are very few—

An Leas-Chathaoirleach

Is the Senator reserving his right to speak?

Mr. Glynn

I am in the hands of the Chair.

An Leas-Chathaoirleach

The Minister usually speaks first.

Mr. Glynn

I was merely moving the motion.

An Leas-Chathaoirleach

I welcome the Minister for Health and Children and I wish him well in his portfolio.

Minister for Health and Children (Mr. Martin)

I thank the Leas-Chathaoirleach. This is my first opportunity to address the new Seanad since the election. I hope to maintain the same constructive relationship with Seanad Éireann that I had with it during my terms as Minister for Health and Children and Minister for Education and Science in the previous Dáil.

Words cannot adequately describe the gravity of the issues examined by this Inquiry and the human loss and suffering that resulted from the infection with HIV and hepatitis C of the haemophilia community. The impact of this tragedy on the haemophilia community has been particularly devastating. The toll in human lives has been great and the loss of so many children is catastrophic. That such an immense tragedy should befall citizens of this State while availing themselves of State health services is a matter of profound regret. I wish to apologise again on behalf of the State and say how deeply sorry the State is that the haemophilia community should have been caused so much suffering.

The public hearings of the tribunal commenced in May 2000 with personal testimony from a number of persons with haemophilia and from members of their families. There were two further sections of such testimony in November 2000 and October 2001. In all, 64 persons gave personal testimony. The tribunal recognised the debt of gratitude owed to each of the witnesses who gave personal testimony, some of whom were very ill at the time, and also acknowledged their courage in coming forward to do so. We all owe a debt of gratitude to those who gave testimony and who spoke out despite their own suffering, in the hope that others need not suffer in the same way in the future.

While considering the bigger picture affecting the haemophilia community as a whole, I am also aware of the need to balance this with the individual view. The story of each individual person and his or her family is important and valuable, and must be listened to. The Government acknowledges the courage of those who gave personal testimony to the tribunal and on behalf of the State I unreservedly apologise to these persons and their families. In order to ensure that these personal testimonies are put on record and given the acknowledgement which is their due, I have decided that they should be published, taking account of fair procedures, as a memorial to the bravery and courage of those who have borne witness at the tribunal. I will also ensure that this publication is undertaken in consultation with the Irish Haemophilia Society, is available at nominal cost, and is circulated as widely as possible.

The Government has decided to accept the findings of the report in full. Having considered the report carefully, it has also decided to refer it to the Director of Public Prosecutions, as a mark of the seriousness with which it views the events documented in it. My officials have already forwarded it to the Director of Public Prosecutions.

The events investigated took place a number of years ago. Significant improvements have taken place since in relation to services for people with haemophilia. The tribunal found that the situation in Ireland regarding the supply of recombinant clotting factor products now compares very favourably with many other countries and was remarked upon by many of the international experts who gave evidence to the tribunal.

We have a state-of-the-art facility at the National Centre for Hereditary Coagulation Disorders. There is ongoing communication between the centre and the Irish Haemophilia Society in relation to the management of haemophilia. A person centred service where the voice of the consumer is a key factor in shaping the services provided is a pivotal aspect of service development. Services at the centre include genetic counselling and testing, dental surgery, orthopaedic surgery and care of patients with HIV and hepatitis C. A full-time psychologist post has been approved as well as a full-time clinical specialist for physiotherapy. A social worker is also in place. The centre provides a single tiered system, with a walk-in service 24 hours a day, seven days a week for patients with haemophilia and related disorders. There is also a same day or next working day service for semi-urgent new referrals. The average waiting time for seeing patients is three months for routine referrals, which is likely to decrease with the addition of the recently appointed consultant. My Department is in consultation with consultant haematologists around the country and the Irish Haemophilia Society to ensure services adhere to the highest standards of quality and that there is optimal co-ordination of services.

I will now refer to the recommendations in the Lindsay report and confirm that my Department is committed to implementing all of them. The first recommendation relates to the quality of the blood products supplied to persons with haemophilia. The recommendation states:

The 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.

Products purchased in this country for use by people with the most common clotting factor deficiencies are no longer made from blood, but are recombinant or synthetic products. Towards the end of the 1990s recombinant products were developed which offered a greater margin of safety with regard to the transmission of infections. At the end of 1997 the Department of Health and Children approved the replacement of plasma-derived Factor 8 with a recombinant product. The replacement process was put into effect immediately during 1998. The Department also approved in advance the replacement of the plasma-derived Factor 9 product. As soon as the recombinant product became available in early 1999, it replaced the plasma-derived product. In that regard, the tribunal found that the situation in Ireland now compares very favourably with many other countries and was remarked upon by many of the international experts who gave evidence to the tribunal.

The second recommendation also addresses an issue of major importance, that is, the establishment of a co-ordinating committee for haemophilia. The Department will proceed with the establishment, on a statutory footing, of a national haemophilia co-ordinating committee, which will be called the National Haemophilia Council. Representation on the committee will include professionals involved in haemophilia care, the Irish Haemophilia Society, representing consumers of the service, health boards, my Department and relevant interests. The results of poor communication and lack of co-ordination of services in the past point to the need for a streamlined uniform system of communication between service providers and a consistent high quality system of care delivered throughout the country. The council will oversee, monitor and advise me on all aspects of haemophilia care. Its overall aim will be to ensure improved communication between clinicians and improved co-ordination of services resulting in a consistent high quality of care regardless of the area of the country in which people live.

The model adopted in the case of hepatitis C works very effectively. The Consultative Council on Hepatitis C was established under statute and meets regularly to consider all aspects of hepatitis C, in particular the organisation, delivery and confidentiality of services; the current and emerging health needs of persons with hepatitis C and the publication of information on hepatitis C. The council operates on the basis of equality and teamwork and has proved a useful forum for pursuing issues of national concern and responding to patient advocacy and consumer input.

A major sub-group of the National Haemophilia Council will be the product selection and monitoring group. A key task of this group will be to ensure all decisions in relation to the selection, procurement, distribution and monitoring of products used in the treatment of haemophilia adhere to the highest standards. The Irish Haemophilia Society will play a pivotal role on this committee, with the National Centre for Hereditary Coagulation Disorders, the Irish Blood Transfusion Service, health boards, and other relevant interests. An ad hoc group is already in place for over a year now and shortly its membership will be expanded to involve key professionals with an expertise in various aspects of haemophilia treatment.

The third recommendation contained in the Lindsay report calls for "greater co-operation and exchange of information among the various doctors who treat and care for persons with haemophilia". My Department is in discussion with the Irish Haematology Society, individual treating consultants and the Irish Haemophilia Society as to how best to progress this recommendation, and will continue to work with these agencies and bodies to bring that process to a successful conclusion.

The fourth recommendation states: "A sufficient number of consultant haematologists should be appointed." Substantial progress has already been made in this regard since Comhairle na nOspidéal reported on the issue of consultant haematology posts in 1999. In 1996, for example, there were just 15 consultant haematologists in the country. In its report Comhairle recommended 39 posts for health boards and a further eight in the Irish Blood Transfusion Service. A total of 27 posts have now been established and a further six which have been approved are in the process of being filled. Three posts not included in the Comhairle report have also been filled in the eastern region.

The fifth recommendation relates to the area of medical records and specifically states: "Medical records should be kept and maintained in a more satisfactory manner." Clearly, the tribunal had found it to be unsatisfactory during the period under scrutiny. The tribunal noted that during the course of its work it was "struck by the unsatisfactory and incomplete nature of the medical records which were available in regard to particular patients." Obviously, this is an area which has to be addressed and we have initiated discussions with treating consultants on the matter.

It will also be necessary for hospitals involved in haemophilia care to examine the record systems in current use and agree on a format for improving record keeping in a consistent fashion. This process will be examined in conjunction with a proposal to develop a national database to which each treating consultant will contribute.

Having addressed the issue of medical records generally, the report goes on to make a recommendation on the records of the national centre in particular. As the tribunal has recommended, a national patient recording system will be developed at the national centre. My Department will explore options for achieving this objective as part of the dialogue on the implementation of these recommendations which has been opened with treating consultants at both the national and regional centres. The Irish Haemophilia Society will also be consulted and kept fully informed about this process.

The seventh recommendation addresses an area of great concern. The recommendation states: "Doctors should ensure that test results in relation to patients are given to them as soon as such results become available, unless there is compelling medical reason to the contrary, and that appropriate support and counselling is available."

In order to ensure every effort has been made to identify, contact and offer hepatitis and HIV screening to any recipient of a blood product that may have been infected, the health boards, in conjunction with the national centre and the IBTS and with the support of the Irish Haemophilia Society, will undertake another examination of hospital records. The consultation process with clinicians involved in the management of haemophilia has commenced. Discussions have also been initiated with the Irish Haematology Society, to which the consultants are affiliated. In the short term, however, all health boards have nominated a consultant haematologist or equivalent to assist in carrying out another examination of all hospital records to ensure anyone who may have been exposed to potentially infected blood products and may still be unaware of the risks from such exposure is contacted and invited for hepatitis or HIV testing. Appropriate counselling and supports will be available to anyone who may be identified in this examination.

The final recommendation refers to procedures to be followed in relation to any new tests. The tribunal report states: "The Irish Blood Transfusion Service should establish protocols to ensure that, with any future new tests for infective agents, positive test results are communicated to the relevant donor as soon as possible, referral is made to counselling services, and look back procedures are put in place." These protocols are currently in place at the IBTS and will continue to be followed in the future whenever any new tests are introduced.

I am grateful to the Irish Haemophilia Society for its close co-operation with my Department over the years. I wish to acknowledge in particular the contribution of Mr. Brian O'Mahony, chairman of the society. Mr. O'Mahony is also president of the World Haemophilia Federation, which is evidence of the high esteem in which both he and the society are held at home and abroad. I must also acknowledge the significant input of Ms Rosemary Daly, who worked tirelessly over the years in the cause of the Irish Haemophilia Society and its members. I understand that Ms Daly is enjoying a well earned sabbatical from her role as administrator of the society and I wish her well for the future.

The society requested an increase of €300,000 in its funding at a recent meeting with me. Having considered the request, I was pleased to inform the Dáil last week that I intend to provide an additional €300,000 to the society next year to enable it to enhance the services it provides to persons with haemophilia. As well as funding for the support groups, the provision of targeted funding for the development of primary care and hospital services has also been recognised by the support groups as being an important element in the overall model of services for persons with hepatitis C. My Department, and successive Ministers for Health and Children, have reiterated the commitment to provide sufficient funding for the continued development of services for persons with hepatitis C and HIV. The consultative council on hepatitis C and the support groups are agreed that funding to date has been satisfactory and they look forward to the continued provision of funding at a level sufficient to maintain and develop services which are responsive to emerging needs.

There has been criticism about the cost of the Lindsay report which was set at €10 per copy. When the cost was being determined it was seen as reasonable relative to the Finlay report which cost £5 in 1995. However, the Irish Haemophilia Society has pointed out that €10 is very high relative to the €1 charged for the interim report of the Flood Tribunal. While the society acquired as many copies as it requested free of charge from my Department, I consider that the point it has made regarding the cost is valid and as a result I will request the Government Publications Office to make the report available at a nominal charge of €1. Copies will also continue to be available from my Department on request, and an electronic version is available on the Department's website.

Calls have been made for a further inquiry into the actions of certain multinational pharmaceutical companies based predominantly in the United States, whose products were implicated in the infection of persons with haemophilia with hepatitis C and HIV. Judge Lindsay considered it inappropriate to comment on whether there should be a further inquiry into the actions of such companies since I had commissioned and obtained independent advice on the matter. I appointed Mr. Paul Gardiner, Senior Counsel, to advise me on a possible investigation into the actions of these multinational pharmaceutical companies. I have had consultations with Mr. Gardiner and, subject to further discussion with the Attorney General, I believe it would be possible to mount a useful investigation which would allow access to publicly available material and to persons and bodies willing to co-operate. Following consultation with the Attorney General and all other parties, including the Irish Haemophilia Society, on an effective template, I will revert to the Government, the Dáil and the Seanad on my proposals.

I know I have the full support of the Seanad in reiterating that while we acknowledge the mistakes of the past, there is an ongoing need to protect and maintain the national blood supply. To ensure that blood is available whenever and wherever needed, it is imperative that donors are encouraged to give blood, and to continue to do so on a regular basis. This year, despite all the adverse publicity, the level of donations has been very high and I commend those who have demonstrated true generosity of spirit by taking time out of their busy schedules to think of the needs of others. However, because of the short shelf-life of blood and blood products, and the seasonal variations in donation patterns, it is essential that people continue to donate blood regularly.

I am sure I speak for all present in expressing our deep sorrow at the suffering that people with haemophilia have endured, and in resolving that a similar tragedy will never happen again.

Mr. Feighan

I welcome the Minister's speech and wish him well in a difficult brief. I also welcome the fact that the Government has accepted in full the findings of this report and has decided to refer it to the Director of Public Prosecutions. I found the €10 price of the report difficult to accept because it demonstrated a certain disdain for the victims. Given that copies of the interim report of the Flood Tribunal were sold for a nominal €1, I felt the Government might have been profiteering from the report of the Lindsay Tribunal.

I welcome the Minister's call for more people to donate blood, which should be made loud and clear. While blood is donated voluntarily at present, we may have to examine the possibility of introducing some degree of compulsion because the IBTS is finding it difficult to find enough donors. I only realised how vital blood supplies were when my brother was in hospital last year and required blood products.

Judge Alison Lindsay was appointed as the sole arbiter – from the Circuit Court, somewhat oddly – of the tribunal established in 1999 to investigate how over 260 haemophiliacs contracted HIV and hepatitis C from contaminated blood products. The tribunal sat for 196 days, gathered evidence from 146 witnesses and cost approximately €13 million. Final submissions were made on 27 November 2001 and the report was published in the first week of September 2002. Over 200 people were infected with hepatitis C, 104 with HIV and many contracted both viruses. To date, 79 people have died, including eight since the tribunal began its hearings. The vast majority of infections were caused by products imported from companies in the US, but an Irish made Factor 9 blood product, manufactured by the Blood Transfusion Service Board – now renamed as the Irish Blood Transfusion Service – infected seven people with HIV. The Blood Transfusion Service Board did not use heat procedure to kill possible HIV contamination for a critical six months in 1985, although the board had been warned of the possible dangers.

The BTSB was also responsible for the imported material. It sounds very much like a Shakespearean tragedy but, unfortunately, it is all true. The main players included the Blood Transfusion Service Board, which seems to have been the main "baddie" in this script. It looks as if it was an incompetent organisation in the 1980s which did not have best practice procedures that we hope would be incorporated today.

The Irish Haemophilia Society was another player. The Department of Health and Children was the ultimate supervisor of the Blood Transfusion Service Board. One Minister was apparently given incorrect information which he gave to the Dáil. I want to know who misled him, and why. Also involved was Armour Pharmaceutical, an Irish supplier, and the other main players were the US supplying companies.

In the United States and Germany, clinics had a reputation for accepting blood from undesirables who were paid $20, $30 or $40 per donation. These were high risk practices in the developing AIDS environment of the early 1980s. The Irish Haemophiliac Society wanted these matters investigated but Judge Lindsay would not broaden her remit. The Minister for Health and Children made a promise in this respect recently for which I thank him. It might be difficult and costly, but cost should not hinder this investigation.

Some people say that Dr. Jack O'Riordain, who was head of the BTSB at the time, was too old and probably incompetent. A major factor was that the BTSB was under-resourced with minimal supervisory structures and then, around 1985, it was hit by a new and devastating blood transmitted disease, HIV/AIDS.

Dr. Terry Walshe, a former BTSB consultant, was involved, as was Dr. Emer Lawlor of the BTSB who, according to the Irish Haemophiliac Society, tried a damage limitation exercise on behalf of the BTSB. Then there was Professor Ian Temperley, former head of the National Haemophilia Centre in St. James's Hospital. According to members of the Irish Haemophilia Centre, he was arrogant and unfeeling and told people in corridors that they had HIV, etc. The report gives him a better reference. However, it criticised him for taking something like six months leave at a vital time in 1985.

While I welcome the report, I like most Senators who spoke must take issue with it concerning its tone and thrust. The group which has suffered in this great Irish human tragedy already has a cross to bear in their haemophilia. That this should be compounded by services provided by the State meant to alleviate their condition is a double tragedy.

This is compounded further by the way it has been dealt with subsequently. Many of their number demonstrated great courage in being witnesses in this most adversarial tribunal in the expectation that their story would be told and justice would be done. The balance always seemed to weigh with those defending their actions against those who just wanted simple answers to simple questions, but our structures cannot allow for such forthrightness. Following this Lindsay tribunal, we must look at the way tribunals are run. Thankfully in recent tribunals there has been a change.

The fact that the story of the victims is on record is a positive outcome of the report, but the reaction from representatives of the Irish Haemophilia Society clearly shows that the report, on which they set so many of their hopes, has once more devastated them after their great efforts and resolve in participating in full. They expected blame to be apportioned but this did not happen. They hoped for a broader investigation of the sources of their grief and suffering, but this was not forthcoming, although we note that this is now promised by the Minister, Deputy Martin, and I welcome that.

Another puzzling omission to which many referred was the fact that no member of the board of the BTSB was called to account. One of the most striking aspects of Judge Lindsay's report is the language in which it is couched. It is as if it has to be in some sense whispered, for example, "a missed opportunity", "should have been pursued with greater vigour", "not appropriate for the Blood Service to put concerns about litigation above tracing people who may have been infected". It most certainly was more than inappropriate that the blood service procrastinated in this way. We are talking about people's lives and the urgency of time.

Another example is that they thought it was not appropriate to send a copy of the report to the DPP. I count it most appropriate and am pleased that this is being done. With many more, I await more positive responses from this move. Once again, I support the Minister's decision. One must remember that we are talking about the deaths of 79 people, the infection of hundreds more with a time-bomb disease, their suffering and the unimaginable suffering of those close to them. Perhaps the French model will be used.

The language and directness of the interim report of the Flood tribunal has set a precedent for future reports. There is disappointment at the lack of findings and conclusions in the Lindsay report and, above all, no apportioning of blame. There are aspirations and we are told it is different now, and so it should be. We should not pat ourselves on the back too much for learning from a disaster of this scale.

The role of the media is to be commended, and especially RTÉ for its presentation in various forms of the issues involved. I am inclined to reserve judgment on RTÉ due to the way it treated the leader of my party, Deputy Kenny, on radio today.

The resolve of the victims and their supporting groups in coping with the magnitude of this tragic train of events deserves our utmost support. I commend the Irish Haemophilia Society for its Trojan efforts on behalf of the victims over the years and the participation of its members in the tribunal. Their courage is an example to us all. It is so sad that they have not been able to get satisfaction from this report. They are the people who suffered, those who count above all else. It seems they must battle on to achieve their goals. This report is not the text they were promised when the tribunal was put in train. The source of 95% of infection was apparently outside the remit of the tribunal. Can we be satisfied with the report of this tribunal, which in essence was in a position to investigate the remaining 5%? The Irish Haemophilia Society is not satisfied and it is they and their families who really matter.

I am disappointed at the results of the Lindsay tribunal and at the way it was conducted. If we have learnt some lessons for the future from it, as I believe we have done with the Flood tribunal, then it is a move in the right direction for the political forces and for the country.

Mr. Glynn

Cuirim fáilte roimh an Aire go dtí an Teach. Is ea a chéad cuairt anseo tar éis an toghcháin ginearálta.

I do not suppose there is another issue which has come before either House of the Oireachtas which has generated more emotion and more sadness than the Lindsay report. It is outrageous to have to say to the nation that this is a situation which need not and should not have occurred. I welcome the opportunity to speak on this important motion which addresses one of the most serious issues ever to have been considered by either House.

The devastation and suffering caused to persons with haemophilia and their families through their infection with hepatitis C is fully acknowledged and referred to by the Minister, my colleague Senator Feighan, and many others. I pay tribute to those who gave such distressing personal testimony to the tribunal of inquiry and who spoke so courageously of their own suffering and the suffering of their loved ones.

The Lindsay tribunal of inquiry into the infection and death of people with HIV and hepatitis C concerns one of the greatest injustices in the history of the State. Regrettably, all we can do is provide funding for the Irish Haemophilia Society and ensure that two important situations obtain, that is, quality control and traceability of blood products. This is absolutely imperative.

The Lindsay tribunal inquired into the infection of more than 220 haemophiliacs with hepatitis C and HIV from blood products which occurred mainly in the 1970s and 1980s. Over 70 people have died as a result of being infected. One of them gave evidence at the Lindsay tribunal shortly before dying. It is outrageous.

As Fianna Fáil spokesman on health in the Seanad and on behalf of the State – I am sure I reflect the views of everybody in this Chamber on all sides of the House – I reiterate the apology that has been made here by the Minister and the Government to the families of the people concerned. Nobody involved in this unfortunate episode can be happy with their role in this disaster.

While most clotting agents were imported from the United States, the BTSB has conceded that two batches of clotting agent which it made had infected seven haemophiliacs with HIV, five of whom have died. Who is to be blamed for that?

The tribunal also heard that the decision making at Pelican House was slow, the BTSB was effectively bankrupt, critical documents were shredded and a senior employee had a conflict of interests. It is not the type of situation which would contribute to good practice. There were also suggestions from the Irish Haemophilia Society's legal team that profit was being put before the product's safety.

The proceedings began with people explaining how contaminated blood products affected their lives. The first person to give evidence was 20 year old Karen Stevens, whose father, Jerome, contracted HIV from a clotting agent given to him during an operation. Karen spoke about the manner in which AIDS crippled her father, brought searing pain and, ultimately, killed him. She was at school at the time and other children refused to play with her because she had the stigma of AIDS. If ever there was a heart rending situation, that is one. She was one of only 30 people who spoke out. Some witnesses, like Ray Kelly, chose to speak publicly. He explained how his 13 year old son died in agony from the AIDs related illness caused by clotting agents. However, most witnesses gave evidence anonymously using pseudonyms and often behind a screen. One does not need to be a rocket scientist to work out the reason they did that. One need only refer to the experience of Karen Stephens.

The stigma lives on after diagnosis. One father told the tribunal it was a relief when his 11 year old son died. Imagine a father admitting that to himself. Surely this is heart rending. As a parent, I certainly know how he felt. Death would ensure the little man would suffer no more.

No words can describe the seriousness of the issues examined by this inquiry and the human loss and suffering which resulted from the infection with HIV and hepatitis C of the haemophilia community. I am glad the Minister for Health and Children has acknowledged the courage of those who gave personal testimonies to the tribunal. Let the publication of their accounts in the report be a memorial to the bravery of those who bore witness to the tribunal.

I am also happy the Government has decided to refer the report to the Director of Public Prosecutions. What else could it do? There can be no hiding place for those who neglected their duty and caused this situation to arise.

The Minister has appointed Mr. Paul Gardiner, senior counsel, to advise him on the possible investigation of the actions of certain multinational pharmaceutical companies based in the USA whose products were implicated in the infection of persons with haemophilia with hepatitis C and HIV. That is what I mean by traceability, which is absolutely necessary for blood products.

The tribunal found that the situation in Ireland regarding the supply of recombinant clotting factor products now compares favourably with that in many other countries and was remarked upon by many of the international experts who gave evidence to the tribunal. I am delighted to be able to say this, but why are we closing the stable door when the horse has bolted? Who was involved in quality control? Who was not doing his or her job?

We have a state-of-the-art facility at the national care centre for hereditary coagulation disorders. There is ongoing communication between the centre and the Irish Haemophilia Society in relation to the management of haemophilia. That is to be welcomed. A person-centred service where the voice of the consumer is a key factor in shaping the services provided is a pivotal aspect of service development. The results of poor communication and a lack of co-ordination in services in the past point to the need for a streamlined uniform system of communication between service providers and a consistently high quality system of care delivered throughout the country. We must be consistent in ensuring the blood products and intravenous fluids we are offering are of the highest quality and that everything is done to conserve the high standard of the product.

I was pleased to hear the Minister say he would provide an additional €300,000 for the society next year to enable it to enhance the services it provides to persons with haemophilia. I am also glad he has requested the Government Publications Sales Office to make the report available at the nominal charge of €1, although I acknowledge the comparison made between the original price and the price of the Flood tribunal report.

While the tribunal cannot take away the pain and loss, the victims repeatedly say they want their experience to ensure such a tragedy can never happen again. Is it not regrettable that the old adage, the cure is often worse than the disease, is true in this case? If the 70 or more victims were alive today, they would tell us why.

Mr. Norris

I have but a few remarks to make because the matter has been rehearsed widely. I am also not the best qualified Member in my group to speak on this matter. If my companion who is a medical doctor comes to the House, I will seek permission to share time with her because her knowledge is considerably greater than mine, as I know from previous experience.

I welcome the Minister's speech which was clear and open. He has adopted a conciliatory attitude to the haemophilia society which I welcome.

I must correct an impression given, perhaps inadvertently, by Senator Feighan in an otherwise excellent speech, that the Department was profiteering. He may not have heard the Minister say he had reduced the price of the report to a nominal €1.

Mr. Feighan

The report cost me €10 today.

Mr. Norris

I see. Then that is a significant point to make.

Mr. Martin

The Department would have given Senator Feighan a copy for no charge.

Mr. Norris

I got a copy from the Oireachtas Library, the library staff acting with their usual efficiency.

While I welcome what the Minister has to say, I find it more difficult to welcome the Lindsay report, which is weak in a number of aspects. Two fairly similar and fundamental questions need to be asked, arising from this tragic situation. First, did medical personnel continue the use of infected material, knowing it to be infected and liable to cause injury or death? If so, this places a large measure of responsibility on them. That is the domestic situation. It is, perhaps, this which the Minister intends to have investigated by referring the matter to the Office of the Director of Public Prosecutions.

The second question is that of the culpability of the multinational pharmaceutical companies. Did they continue to make products commercially available which they also knew were capable of causing injury and death to innocent patients? These are the two principal questions which must be answered and it is important that they be answered. They are not satisfactorily answered in the report. In fact, certain issues are skirted or avoided.

Underlying this question there is a financial motive on the part of the medical services which, in a situation of budgetary stringency, appear to have wished to cut down on their costs and may have used this as an excuse for using possibly infected material. There is even correspondence on the record of the tribunal which indicates that this may be the case. It may well also be that for motives of profit the large multinational companies took the same attitude.

There is a letter written by Professor Ian Temperley in 1988 when the situation was fairly well developed. We had the first real knowledge of AIDS in 1981 and the first known infection of a haemophiliac in Ireland was in 1984. I have the greatest sympathy with Professor Temperley because he is a professional man and on most occasions acted in the best interest of his patients, to whom he was devoted. He was complimented in the report on having answered courageously and taken neither a defensive nor an evasive attitude. As a result, this material was placed on the record. Professor Temperley wrote:

The Board should understand that in the present period of financial stringency the hospitals could not be expected to meet a doubling of the cost of concentrates in 1989. Some balance will have to be struck between cost and the infection dangers associated with blood products.

This is a judgment I would not wish to have to take because it is almost one of life or death in the light of a clearly stated financial background. That is worrying and needs to be looked at.

It is rather astonishing to look at the development of the response to the report, which highlights many of the weaknesses therein. On 6 September a report in The Irish Times stated, “Judge Alison Lindsay has produced a detailed and comprehensive report and she and her team are to be congratulated for the professionalism with which they carried out their task.”

On the same day another headline in the same paper said: "Haemophilia group welcomes ‘landmark day'." However, in another part of the paper the questions were already beginning to be raised. Some degree of dissent was expressed by the Irish Haemophilia Society, which criticised the Department of Health and Children for aspects of its handling and indicated clearly it was disappointed that the report did not clearly put on record a finding that the BTSB did put profit ahead of safety in the treatment of its patients. A week later, the same paper is full of intense and detailed criticism of the report. In fact, it compares it very unfavourably in terms of both timescale and cost to other reports, particularly the Finlay report, which took a considerably shorter time to be issued and cost considerably less.

The Irish Haemophilia Society itself began to become increasingly agitated and angry in the middle of September. The persons representing it said it had been looking for the truth but what it found was evasion. One went so far as to suggest that the State had been implicated in what was described as the "murder" of a relative. That is very strong language. Although this alludes to a very tragic occurrence – I too remember Jerome Stevens and his courage very well – I do not think I would go so far as to say this was State murder, but there are certainly very serious questions to be asked.

They have also suggested the report missed the human element. This is something we must certainly guard against. For example, the report in its conclusions, which are at least concise and clear, states that there should be relative speed in making information known to patients about possible infection, but they say very little about the manner in which this information should be passed on to the patients. The report is full of incidents in which patients were made aware of things in a most unfeeling way, as has been stated already in the corridors of hospitals. Yet, the report does not seem to address this subject in the way it ought.

Questions have been left unanswered by the report. We may need to take some share of the blame here in the Houses of the Oireachtas. Perhaps the brief or terms of reference that were given made it difficult for the judge to arrive at the speedy and very clear pinning of blame many of us would like to see, but there are instances of clear conflicts of interest in certain cases, some of which have been raised.

Seán Hanratty, a former BTSB senior technical officer, was a founder shareholder in a company which imported products believed to have infected many haemophiliacs with HIV. He was simultaneously the BTSB official in control of key internal documents destroyed in 1993, but neither this incident nor Mr. Hanratty's role in product selection was openly factored into Justice Lindsay's deliberations on the BTSB action.

Further investigative methods were necessary on the part of this tribunal that did not come into action. I will give one other instance. There was contradictory evidence between two doctors, Professor Ernest Egan and Dr. Terry Walsh. Professor Egan, for example, maintained that he had informed Dr. Walsh of the infection with HIV of one of his patients through the blood transfusion services in January 1996. There was a conflict of evidence and Dr. Walsh said that he had not been so informed as far as he could recall. However, although the judge said she believed he had been informed, she did not go much further than that. It is an astonishing thing to say that a doctor had been informed that a patient had been infected with a blood product and nothing was done and that the same kind of treatment continued.

The question of the board of the BTSB then arises. The conclusion of the report is that the board was not entirely blameless. That is pretty vapid stuff. How do we know anyway? It looks as if there was certainly a level of culpability, and why were they not called in as witnesses? These are fairly glaring defects in the production of this report. In that context, it makes it extremely difficult to welcome it, although I welcome the Minister's response and the fact that he has taken on board virtually all the recommendations of the report and that he has given us guarantees, in so far as they can be given, that this kind of thing will not occur again.

It is very important to reassure the public, particularly with regard to blood transfusion, because we may all depend on this service at some stage after an accident or operation. From my own school days I know that there are dips and flows in the blood supply. I remember we used to get appealed to in university to give blood. I have never done it. I was always excluded because I had knowledge that I was gay and there was a big political controversy about whether gay people should be allowed to give blood. I was glad not to in a way because I hate needles and injections. Later, through taking water in Budapest, I contracted a peculiar and rare form of hepatitis – not types A, B or C – that ruled me out for life. Also, incidentally, it got me a pension from Trinity, regarding which I was rather grateful for the collaboration of my liver. I am particularly grateful that it was not one of the apparently more virulent forms of hepatitis, but it does give me some sympathy with the human element of the people who were involved in these tragic circumstances.

It is very important that the standing of the blood transfusion services now be validated and supported and its image strengthened so people will be able to give and receive blood in confidence. I congratulate the Minister on his response. I do not wish to be a naysayer but I cannot in my heart congratulate the Lindsay tribunal on its report. It is weak, vapid, inoffensive, passive in tone and not at all sufficiently clear or investigative.

I return to the two questions I asked, which the ordinary person – I am one and have no medical qualification whatever – will want answered. Did medical services knowingly continue to treat patients with material they understood and realised to be infected and capable of causing serious risk to health, and indeed death? Second, did the multinational corporations still continue to make these products available although they possessed the same level of knowledge? Those are the two simple questions people will want to have asked and answered. In those questions lie the kernel of what appears to me to be a criminal responsibility for the death of some of our fellow citizens.

I salute the bravery of those who had the courage to give evidence. I deplore the fact that, because of the stigma surrounding this tragic disease of HIV, so many of them felt they had to give evidence under a pseudonym. I hope the Minister will continue efforts to remove the stigma from what is, after all, a disease. The one level of criticism I have of some elements within the haemophilia community is that in the early days when they were negotiating for money and help – and now I think they get it very easily after an initial reluctance – there was a tendency among some of their supporters to say that they had acquired this infection blamelessly. Morality should be kept separate from the treatment of illness, first because this is the humane approach and, second, because it is the safest. If shame is used to drive disease underground a timebomb will have been created.

Mr. Minihan

I welcome the Minister to the House and wish him well in his most difficult brief. I am sad that on his first visit to the House we are debating such tragic events. The events that gave rise to the Lindsay tribunal took place many years ago and much of the evidence was of a historical nature.

Under its terms of reference, the tribunal's sole member, Judge Alison Lindsay, was required to discover a number of key points. These included, first, which relevant products caused or probably caused the infection of haemophiliacs with HIV and hepatitis C; second, when the board of the BTSB and other relevant persons in the State became aware, or ought reasonably to have become aware, that relevant products had become, or that there was a risk that they would become, a source of infection; third, the adequacy and timeliness of the response of the board and other relevant agents of the State to their becoming aware that the relevant products had, or that there was a risk they would, become a source of infection; fourth, the considerations that influenced the decisions of the board and other relevant persons in the State in the selection of the manufacturers of these relevant products; and fifth, the standards and procedures applied by those manufacturers in respect of donor selection, screening and testing and plasma quarantine, virus inactivation and product recall. We should bear this in mind.

The tribunal did much good work. For example, we now know which products were a source of infection. However, it failed to establish with any degree of certainty when the manufacturers of those products discovered that their products were a source of infection. It is by no means certain that we now know the full extent of the BTSB's knowledge as this body, unlike other State bodies, refused to waive privilege in respect of its legal advice. Consequently, the tribunal was an opportunity missed.

The tribunal was established to discover how 252 people with haemophilia contracted HIV and hepatitis C from contaminated blood products administered by agents of the State and supplied or manufactured by a statutory corporation established in 1965 under the Health (Corporate Bodies) Act, 1961. Haemophiliacs looked to Judge Lindsay to provide closure on the terrible ordeal they endured over the past 20 years. They required answers to how and when it happened and who knew.

Throughout the tribunal numerous haemophiliacs and their families came forward to tell their stories. Judge Lindsay correctly states in her report that their evidence was at times sad, tragic and harrowing. It was the authentic voice of those whose lives had been touched and irretrievably altered by the infection. Judge Lindsay went on to express the belief that the tribunal had provided a forum in which the voice of haemophiliacs could finally be heard.

While I agree that the tribunal provided a valuable forum, this was only a side issue for haemophiliacs. They wanted the truth, as is clear from the authentic voice of those who lived through this nightmare. On 2 May 2000 Ms Karen Stevens told the tribunal about her father Jerome who contracted HIV from infected factor 8 and subsequently died of AIDS in February 1993. When asked by counsel what she hoped to obtain from the tribunal she replied that she wanted her father back but she realised that was not possible. In these circumstances she wanted answers to what had happened so that she could put the ghosts of the past to rest. I am afraid she cannot do so.

Later that day, Mr. Raymond Kelly told the tribunal of his son John who died in 1994, at the age of 13 years, as a result of HIV and hepatitis C infection. Concluding his evidence Mr. Kelly said he wanted to know who made the decision to import blood products from the United States and if they knew they were infected. He went on to say that if they did know the products were infected but nevertheless put them into circulation, then they had murdered his son. He asked who was responsible. Again it must be asked if he now knows.

On 8 May 2000 the tribunal heard from Mr. John Berry, a 62 year old haemophiliac who was diagnosed with hepatitis C in 1991. He expressed the hope that the tribunal would discover what went wrong with the system of looking after those with haemophilia, that it would ascertain who made the mistakes and that those responsible for the health system would ensure that nobody is again treated with dangerous products. I am afraid he does not know even now who made the mistakes.

Also on 8 May 2000, Vincent, a 34 year old married man who was diagnosed HIV positive in January 1986, said he wanted to know what went wrong. He said somebody made a mistake and he stated: "I answer for my mistakes. So should they." Does Vincent know what went wrong and will those responsible have to answer for their mistakes?

On 30 November the tribunal heard from Ms Linda Dowling, who described the death of her father Joe from AIDS as a result of his treatment for haemophilia. Concluding her personal testimony Ms Dowling said she would like the United States pharmaceutical companies to be investigated as one of them had infected her father. In view of the Minister's statement I am hopeful this investigation may take place and that she may get answers.

The testimony of these five witnesses is a small sample of the evidence given by those who have lived this tragedy. They want closure, but above all they want answers. In this respect the Lindsay tribunal was an opportunity missed. While I welcome the fact that the Government has forwarded the report to the DPP, there is a job to be finished.

After months of taking evidence Judge Lindsay was reluctant to make detailed recommendations in respect of the arrangements for the treatment and care of people with haemophilia. However, she made one recommendation with which I agree. In her opinion the blood products supplied to those with haemophilia should be of the highest standard and of the safest type available. The tribunal believes, as I do, that this situation prevails, but it must continue to be the case.

This issue affects not only haemophiliacs but concerns us all. In at least 30% of cases with haemophilia there is no known family history and the occurrence of haemophilia is presumed to be the result of spontaneous genetic mutation. It is not just an inherited blood disorder but can affect any family.

I welcome the fact that the Minister is taking on board the many good points made in the report, but there is also an onus on him to finish the job by providing the victims, the survivors, haemophiliacs and their families with what they want most – answers. In fairness to Ms Justice Lindsay, she could only work within, and to, the tribunal's terms of reference, to which Senator Norris alluded. I fully agree with him. Perhaps the terms of reference were not specific enough and should have been more detailed. Ms Justice Lindsay was tough in her own way. The use of moderate language should not be interpreted as weakness. The comparisons made between the reports of the Flood tribunal and the Lindsay tribunal were unfair. The events being investigated were totally different and the language used in each report was appropriate to the nature of each matter.

There are people who jump on the bandwagon and play on the misfortunes and emotions of others for their own personal gain or profit. I support the assertion of Senator Norris in regard to those highlighted as having a conflict of interest. In this regard, I ask the Minister to indicate what, if any, moneys have been paid, or sought to be paid, from his Department in connection with the public relations activities of any interested parties attached to the tribunal. I urge him to provide haemophiliacs with what they want most – answers. We all hoped the tribunal would do this, but in that respect, as I have said, it was an opportunity missed.

Mr. Ryan

There is a consistent theme running through the debate up to now and I do not want to spend the time allocated to me just repeating what other Members have said. If we, as a society, are to learn anything from this appalling scandal, it must be that all public bodies should have clearly defined lines of accountability. It is the duty of the Oireachtas to ensure this is the case.

Many have commented unfavourably on the nature of the extended debate on the report of the Flood tribunal and the apparent lower profile of the debate on the Lindsay tribunal. It is easy to have a serious political conflict about the Flood tribunal, whatever one's views or position, but this is much more of a human tragedy and I consider it a tribute to the good sense of politicians that a responsible approach has been taken. The views on the kind of report produced by Ms Justice Lindsay have been tempered by the understanding that we are in an entirely different realm of scandal. There is no comparison in any objective sense between the matters investigated by the Flood and Lindsay tribunals, in terms of the damage that has been done.

Decisions should never be taken by a public body, whether it be the Oireachtas, a Department, a health board or VEC and so on, where it is not possible to identify who is responsible for them. There has been a mythical concept of the accountability of the board. Health boards, in particular, are famed for statements prefaced by "I am directed by the Minister". If every letter that begins thus was actually dealt with by the Minister, then he or she would not have any time to do anything but write letters, such is the scale of it. The honourable and well-intentioned determination to make sure there is clear political accountability for public bodies, whether it be a health board, VEC or Department, has created confusion and uncertainty about who is responsible for what. The next stage in the process of transforming our public service is to identify who is responsible.

We have to reach a stage whereby an appointment to a State board is seen for the responsibility it entails, not as a reward for political service nor a statement of status. I am not making a political point, as my own party was also good at this. In the case of the Lindsay tribunal, it is quite right that employees were investigated, but they were merely agents of the board. I do not know the reason Ms Justice Lindsay did not require evidence from the chairman and members of the board. Perhaps there was a good reason. If we are ever to get satisfactory answers to the questions of the people who have suffered in this appalling scandal, then we have to clearly identify who is responsible.

I have no desire to see anybody go to jail. I am not interested in finding out who did what, whether it be in the Flood tribunal, the Moriarty tribunal or any other tribunal. I am not a fan of prison and I am not convinced that it does much good for anybody. I am not in favour of old men, in particular, going to prison. I have said this before in respect of such people as General Pinochet. I want to see a clear identification of culpability by a competent court or tribunal. I am not interested in the imposition of penalties because it has an overtone of retribution.

I am concerned – public opinion is also concerned about this in regard to a number of areas – about the clear absence of identifying who was responsible. It is not just a public sector matter. There are people who claim status and, in some instances, income, which they justify on the grounds of the responsibility they bear. In the case of the recent scandal involving one of the big banks, for instance, there was a similar ethos. People were awarded huge salaries because of their alleged huge responsibilities. It turns out that those responsibilities seem to be theirs only if matters are going well and once they go wrong they are no longer responsible. If one is paid to be responsible then one is responsible for what is done in that public body whether it works or not. One cannot selectively claim the credit for the good things and say that he or she is not to blame for a problem because they did not know about it. The board of this public body was not investigated.

I do not believe the boards of public bodies have ever been enthusiastic about grappling with the responsibilities of a board of directors. It ought to be similar to the responsibilities of a board of directors in a public limited company. The responsibilities are to determine basic strategy and delegate the executives to carry it out. The basic strategy should not be determined by the employees, presumably they should make a major contribution to the determination. I work in the Cork Institute of Technology. The director of the institute does not determine the basic strategy, rather it is the governing body. It is not a titular thing, it is a clear responsibility. People in public bodies should understand that if the board is found to be culpably negligent in its responsibilities then its members are personally liable for that. Where there is culpable negligence – as there clearly was in the Blood Transfusion Service Board – it cannot be said that nobody of executive or board level responsibility was blameworthy.

I know what the response to that assertion will be and it is probably true. If one was to clearly state that boards were responsible for the actions of their bodies – which seems reasonable – there would be great difficulty in finding anyone to serve on them. I am not talking about people being blamed for bona fides mistakes; I am talking about negligence. If a public body is negligent about fire safety in its buildings, its executive and board should realise that if something happens – and it is shown that it knew there was a problem with fire safety but did nothing about it – they will be personally liable for the consequences. That is what being responsible means but it is missing from this report.

Many things are explored in this report and people have spoken about the strange language used in it. I do not claim to have read the whole report but it seems that Judge Lindsay went out of her way to defend certain people against accusations that were made. She comes to Professor Temperley's defence when people criticised his attitude and demeanour, etc., and said that she did not believe it to be true. She is entitled to do that, but a little bit of criticism of people who did not live up to their standards would also have helped. It is hard to find this in the report. Too many words like "inexplicable" are used. There is too great a belief that it is only the employees who are culpable. A board is supposed to have responsibilities; it is not a token to fulfil a legal requirement.

I do not want to start a row but the motion would have been better if it did not have a slightly self-serving tone. Why does a motion on such a heart rending scandal have a section that "support[s] the Government commitment"? We do not need a motion that says how wonderful the Government is. It is an appropriation of this report to include "acknowledges the high standard of care currently being provided to persons with haemophilia". I do not know that we have high standards of care for all people with haemophilia. That is an opinion and a judgment and it is out of place in a discussion like this. I do not have a problem with a motion that recognises what is in the report, or that identifies some of the deficiencies. I regret that the House will have to vote on a motion that contains many things one would agree with but some of which are contentious and unprovable. How does one prove a high standard of care is currently being provided to people with haemophilia? Phrases like "supports the Government commitment to ensuring the availability of an adequate and ongoing supply of clotting factor concentrates—"

Mr. Martin

That is fair.

Mr. Ryan

It is not fair. A commitment on this extends far beyond the Government, it extends to the Opposition, the medical profession and the health boards. The language of the motion is typical of that of a Government amendment to an Opposition motion which seeks to defend the Government's position.

Mr. Martin

I would not have thought that was intended.

Mr. Ryan

I started by saying that I thought it was insensitive, I did not make any accusation about it trying to be political. It is thoughtless. Fine Gael and Labour endeavoured to have the last two paragraphs of the motion removed but were late with the amendment. The Cathaoirleach, using his perfectly acceptable discretion, did not accept it.

The fundamental issue is the deaths of 79 people. The second issue is the identification of the absence of clear lines of responsibility in public bodies and the need to ensure that clear lines of accountability will be in place in the future.

Dr. M. Hayes

I have some sympathy with the point raised by Senator Ryan. I unequivocally support the paragraph which supports the Government decision to refer the report to the Director of Public Prosecutions. I cannot put my hand on my heart and say that services are above reproach. I am encouraged by the tone of the Minister's reply, it was compassionate, measured and sensible. It is the decent thing to do and I am not surprised the Minister has done that.

I found this to be a difficult report to read in two senses. It is difficult to read by way of organisation and presentation. While I do not want to put those who compile such reports into straitjackets, it would be helpful if a convention could be developed by which reports would be presented in a digestible way. There are differences of opinion about whether there can be an executive summary or recommendations should be presented in such a way that the conclusions are clearly apparent. I found that difficult. I do not disregard the work that went into the report or the great effort of Ms Justice Lindsay. The language of the report and the judgment is not always the language required to deal with the passion of such a situation.

I also had difficulty with the report in terms of the emotion and suffering behind it. We owe an enormous debt of gratitude to the people who appeared before the tribunal, particularly members of the Irish Haemophilia Society, which has fought its corner for so long and without whom it is unlikely the issue would have been brought to this stage. The most worrying and damaging aspect of this is these people approached the State and its agencies for care, which was given on behalf of all of us, and they were more damaged as a result. People who participate in tribunals seek the truth, whatever that may be, or justice – they are not always the same – and it is sad that those who are most damaged by the actions of the agencies feel most bruised by the outcome of the tribunal while those who may have been culpable are mopping their brows in relief.

That is why the report should be forwarded to the Director of Public Prosecutions. It is all very well to talk about systemic failure but systems are manned by people who must take responsibility for the systems they operate and I was taken by Senator Ryan's remark in this regard. I am not sure whether there was a departmental representative on the board because, again, this was another issue that was difficult to dig out of the report.

Mr. Martin

There would have been at the time.

Dr. M. Hayes

The Minister might examine the function of that person. Is the person there to monitor or act as an early warning system?

Mr. Martin

We have discontinued that.

Dr. M. Hayes

I have experience of dealing with this issue on a policy basis in Northern Ireland and I am aware of the difficulties surrounding the emerging knowledge at the time and at what stage people might have been expected to know but there is little doubt that one third of the way through the 1980s the question of the treatment of products was accepted and I am surprised there were not major warning signs earlier about the dangers of using blood taken from infected donors. This relates to the point raised by Senator Norris regarding whether people knew. If people were not aware of what they should have known professionally, was that not a concern of the relevant professional disciplinary bodies and others?

One of the conclusions I draw from the report is that it might discourage people from rushing to set up tribunals willy nilly as the sole means of finding out the truth. This issue might well have been handled better by means of a criminal investigation, as happened in France, for instance. People were held accountable there at the end of the day. I am not one for locking up people but, nevertheless, in terms of our methods of getting at the truth, a tribunal is not necessarily the best one. I would prefer to deal with the criminal investigation first and then establish a tribunal to see what lessons could be learned in terms of how systems are organised because there is a real danger if one is mixed with the other that people are given a little inviolability or they are put in double jeopardy or the possibility of a successful prosecution is made more difficult afterwards.

We have a problem in our society of how to get at the truth. I prefer to go down the avenue of criminal investigation and prosecution and that is why I am glad the Minister has sent the report to the Director of Public Prosecutions. However, behind all this is a huge mountain of suffering which is continuing for people. I welcome the approach adopted by the Minister as it is time to go the extra mile for those who have suffered. The last thing we want is to be penny pinching with these people. They have suffered long and grievously and if money can ameliorate or improve their circumstances the State should provide it. We should also try to establish the facts of the cases but, above all, we should learn from what happened.

I commend the general trend of Senator Ryan's remarks. When people are appointed to boards, they are not there as ornaments. They are there to protect the public interest and to ensure policies are formulated with professional advice and the professional staffs involved are answerable in an open and transparent manner. If we can learn that from this tribunal, it will be something. We must wait for the next stage to unfold and, in general terms, I support the motion. I also support the approach the Minister is taking. We should be grateful to him for taking the responsibility to apologise to people for a grievous wrong that was done to them.

Ms Terry

I thank the Minister for taking so much time out of his busy schedule to be with us to debate this extremely important report. The one word that comes to mind is why. The families of those who were infected with the contaminated blood products were asking why before the tribunal commenced and they are still doing so because they did not get the answers to their questions. The report is not well produced and it is difficult to find conclusions therein. More importantly, Ms Justice Lindsay failed to find anybody culpable for what happened to those who were infected or to find the multinational companies culpable. It is, therefore, an extremely disappointing report. Perhaps the terms of reference were not adequate to ensure those questions would be answered.

I join the Minister in extending sympathy to all the families who have been affected. Their pain continues and many people are still suffering and live with what happened on a day to day basis. They must be to the forefront of our minds as we discuss the report. It must be extremely difficult for them to listen to the ongoing debate. I do not have any doubt they are frustrated that they have not got answers. It has been recognised that they were wronged, which must bring them some comfort. However, we know from the Irish Haemophilia Society that they are disappointed with the report. I understand that. I extend my thanks and congratulations to them for the strength they showed and continue to show. It must have been difficult for them to appear as witnesses at the tribunal.

I congratulate the Minister on implementing the recommendations in the report. That must be done as quickly as possible. We owe it to the people who have died and to those who are still suffering. We must ensure that it does not happen again. The State had a responsibility for the health and welfare of these people. However, we failed many people. The Minister must ensure that this or something similar does not happen again.

I am delighted the report's findings will be sent to the DPP. Perhaps we will then get an answer why this happened. I hope the multinational pharmaceutical companies will be held accountable. Did they know these products were contaminated and continued to give them to innocent people?

I am glad the Minister has decided to reduce the cost of the report. I do not think there will be a queue of people to buy it, as happened when the Flood report was published. That is probably a reflection on our society. Given the cost of the tribunal and the fact it ran for two years, it is a pity we did not get better value for it. It is not right that many questions remain unanswered after three years. By sending this report to the DPP and by implementing the recommendations, we will finally get answers and we will be able to ensure that our blood products are safe in the future. I wish the Minister well and I am confident he will be able to implement the recommendations.

I would have preferred if the second last paragraph of the motion had not been included. It is not a time to clap ourselves on the back. We are obliged to do whatever we do. While I cannot support the motion, I support the principle of what the Minister is doing.

Ms Feeney

I thank the Minister for taking time out of his busy day to stay with us for the duration of the debate. Some of his colleagues were criticised in the past for not spending time listening to the Members of the Upper Chamber. It shows the type of man and Minister he is that he has decided to stay here to conclude the debate this evening.

I defend the motion. Perhaps Members on the other side of the House have misread it. We commend the Government for implementing the recommendations of the report and for supporting good standards. That has always been the case, regardless of what Government is in office. We have always supported high and proper standards.

I welcome the opportunity to debate the Lindsay report. One can hear the note of pain and sadness in the voices of the Members who have spoken on this issue. This became an issue in the mid 1980s when a virus, which the professionals did not know about, was detected in blood. We all recall the sad plight of Mrs. Brigid McCole which was brought back to us recently in the series, "No Tears". That led to the establishment of an inquiry into the role of the blood bank. We are all aware of the row between the blood bank in Cork and Dublin. Dr. Jane Power did great work to highlight the mistakes made and the location of the virus.

We all know about the young men who suffered from haemophilia and who regarded the introduction of Factor 8 as the treatment which would transform their lives. Factor 8, which was a clotting agent, was a wonderful treatment. Prior to its introduction, if young haemophiliacs bled, the blood seeped into their joints which caused deformity. We saw deformity in men in their late teens and early twenties, thirties and forties. One can only imagine the excitement and joy of those young men and their families when Factor 8 came on stream. The professionals felt there was something wrong during the mid 1980s. However, they had to wait until the early 1990s when the virus was identified. By then, however, it was too late as haemophiliacs were already suffering from hepatitis C and HIV. We know now that the blood was not properly screened and treated. The horrific part is that the donor pool was identified. Like Senator Norris, I want to know if it was allowed to stay in commission and to be used for other people.

Neither I nor any politician often compliments the media. However, I take my hat off to them for the excellent coverage they gave to this sorry saga. Only for the excellent press coverage and the good journalistic skills of those men and women and for RTÉ programmes, such as "Prime Time", "No Tears" and "Bad Blood", we would not be educated about the sorry facts.

Many health care professionals are disappointed that the Lindsay report was not strong enough. I, like Senator Terry, note the profound disappointment of the Irish Haemophilia Society expressed through its chairman, Mr. Brian O'Mahony. We all heard their stories here today, which were well articulated by Senator Minihan. I am sad and upset that those most affected by what happened did not seem to get any solace from the inquiry's findings. However, I do not lay the blame at the door of Judge Alison Lindsay and her team. She delivered a good report. Nevertheless, I agree with other speakers that her terms of reference were too narrow. Senator Ryan is correct to state that political gain should not be made from this issue. I do not believe anybody would try to do so given the sensitivity surrounding the report.

I will draw just one comparison between the report and the interim Flood report. Unlike Mr. Justice Flood, Judge Lindsay was bereft of sharp teeth and had no mechanism to name and shame. I regret that was the case. Yesterday's debate was justifiably very heated. As Senator Ryan pointed out, discussion of the interim Flood report is bound to be politically charged for good reason. Money and planning, no matter how grave the issues in question, do not equate with the loss of a single human life, not to speak of 79 lives. It saddens me that 260 people were infected due to this blunder. I agree with Senator Maurice Hayes that we must examine how this terrible tragedy occurred. The report is just the first rung on the ladder. If those who are suffering took no solace from the report, I hope their day will come and the ghosts will be laid to rest. We must ensure we benefit from the lessons we are learning from the Lindsay tribunal and, most of all, never allow it to happen again.

I briefly turn to some of Judge Lindsay's recommendations. It is clear the Minister is committed to implementing all the report's recommendations. The report recommended that there be greater exchange of information between professionals and that steps be taken to ensure a sufficient number of haematologists are available to provide an adequate service for haemophilia sufferers. While researching this issue this morning, I telephoned Comhairle na nOspidéal and was pleased to learn that the number of haematologist has risen from 15 in 1996 to 33 today. The number of haematologists in the blood bank has also increased from four to six. I thank the Minister for keeping an eye on this area and hope the figure will continue to increase.

I encourage health professionals to report inferior standards. Whistle-blowing should not be treated as a bad word but used as a tool to protect society. We must never forget this tragedy, the victims who lost their lives and the families whose lives have been fragmented beyond imagination.

I compliment the Minister in progressing the compensation package. When matters such as this become bogged down, one needs somebody with a firm hand to move matters along. The Minister did this in a very sensitive manner. I support his decision to forward the Lindsay report to the Director of Public Prosecutions and compliment him on seeking advice from senior counsel on the role of the pharmaceutical industry in the affair. Perhaps Judge Alison Lindsay did not examine this area because it was not in her remit to do so.

Mr. McHugh

I welcome the Minister. This is a very sensitive issue which I find great difficulty in debating. If any heroes emerge from the affair, it is the Irish Haemophilia Society for its trojan work and endeavours. The group deserves to be commended and I appreciate the Minister's decision to allocate €300,000 to it last week. Is it, however, enough? Although I accept the IHS is an ad hoc group, has provision been made to mainstream it?

We have all encountered people who were affected by this issue, no more so than in County Donegal. Mrs. Brigid McCole, who passed away in October 1996 at 54 years of age, was such a person. I will not dwell on the details of her case, except to highlight the letter she received from the Blood Transfusion Services Board 12 days before she died in which it was stated that while the BTSB accepted responsibility for her condition, Mrs. McCole would face legal bills if she failed to win her legal case.

Mistakes have been, but today we are not in the business of apportioning blame. While I welcome the Minister's public apology on behalf of the Government as an important step, did we go far enough, particularly with regard to the terms of reference of the Lindsay tribunal?

Senator Terry referred to culpability. As the Irish Haemophilia Society has pointed out, we are nowhere near identifying who is culpable. Like Senator Maurice Hayes and Senator Ryan, I welcome the decision to forward the report to the DPP. I also welcome the initiatives and controls to be introduced in the Department for Health and Children to prevent a future tragedy. The kernel of the problem, however, is that we must consider the feelings of the people who are enduring pain today. This is where the Lindsay tribunal did not go far enough. Not alone should the report be given to the DPP, but the Minister for Justice, Equality and Law Reform should also be involved in the matter. The 79 people who were murdered, albeit inadvertently, have relatives who have to live with this for the rest of their lives yet, according to the report, nobody is culpable.

The reason this is a matter for the Department of Justice, Equality and Law Reform is the families are seeking justice. Despite the tribunal and the possibility of compensation, they require justice. As this is a matter for criminal investigation – perhaps that sounds a little radical for the Minister – the Minister for Justice, Equality and Law Reform should have been included in the terms of reference of the tribunal.

The Lindsay report deals with a very sensitive area and is not a matter for party political debate. I concur with Senator Feeney's remarks on the emotional nature of the issue given that people have lost their lives and other lives will be lost. I offer my sympathy to those affected. As I wish to avoid concluding on a negative note, I reiterate my welcome for the measures announced by the Minister.

Mr. Leyden

I join in the welcome extended to the Minister for whom it is possibly difficult to be here given the circumstances. He is here to represent and speak for the Department of Health and Children and the Government, although he was not a Minister during the period under discussion. I thank him for staying in the House for the full debate, which reflects his personal concern. Senator Feeney made her remarks very well. She is emotional about this subject, as is everyone who has any involvement with it.

I served in the Department of Health and Children from 1987 to 1989 and was not delegated any responsibility for the Blood Bank. That was not my wish because no one could have anticipated the effects of the workings of the Irish Blood Transfusion Service on haemophiliacs and those who contracted hepatitis C. The former Minister, Deputy Noonan, has been unfairly treated in this regard. He is not a doctor or a scientist, but an extremely able politician who, as Minister, was advised by departmental officials to take a certain line of action, which he did. He has stated he regrets this, but such are the difficulties of being a member of Cabinet, as the Minister will know from having to take decisions every day of the week. The Minister has issued a profound apology to those affected, 79 of whom have been murdered by the State while a further 260 are infected and face a very bleak future.

The Department was not aware of the haemophilia issue when I served in it. A Dáil motion in the name of Deputy Howlin, on behalf of the Labour Party, seeking a trust fund of £400,000 to assist haemophiliacs, was rejected by the Government on the basis that it could not enter into commitments. The effect was to bring down the Administration which had been supported by Alan Dukes through the Tallaght strategy. The decision was the wrong one and I tried to avert it in any way I could.

It seems to have been ignored – it may not be known – that a committee was established by the Department which I was given the responsibility of chairing, but its report was never published. I call on the Minister to publish that report which contains nothing that would be damaging to the Government. I spent a considerable amount of time working with the Irish Haemophilia Society and its members during which we had very detailed discussions as to how we could assist them. Extraordinarily, Judge Lindsay does not seem to have been made aware of the report and if that is the case, she should be. It is the responsibility of the Department to make the report public and publish it. It is straightforward and contains many recommendations which could be of use even to this day.

I am delighted that the Minister is establishing an organisation to deal with the Irish Haemophilia Society on a proper basis. The problem with the tribunal was that Judge Lindsay sat alone when no tribunal should be judge, jury and executioner, including that of Mr. Justice Flood. The tribunal was more judgmental than judicial and Judge Lindsay spent a considerable amount of time taking extremely difficult testimony from those affected without backup and support from fellow judicial appointees. She had a very lonely decision to make. Those responsible in this case must pay the price for the effects on the lives of the 79 who have died and the unknown numbers who will, unfortunately, die in the future because of their actions. The people concerned did not die from haemophilia, but from the treatment of it.

We are all responsible in the Oireachtas. The Government, acting on behalf of the State, issued the profound apology which the Minister has reiterated. I am aware of his feelings on this issue with which he has dealt extremely efficiently and with a most caring attitude to those affected. Over the course of the many meetings that took place it was the Minister's regular interventions which allowed the proper approach to be taken by the Department. It was a very difficult period for the Department and its former Ministers who had to be guided by their officials.

We should not merely name and shame. The Office of the Director of Public Prosecutions is an independent body and must examine the role of individuals responsible for cover ups to ensure they face trial, put their defence and take whatever consequences ensue. There is no defence for the deaths of 79 people as a result of the lack of State control of the Irish Blood Transfusion Service. This will be returned to in the future unless the Director of Public Prosecutions takes the required action now and puts those responsible on trial. Even if they can defend themselves, at least the families affected will see exactly what role they took in that regard.

The Minister should extend the inquiry to cover the American aspect and obtain compensation from the product suppliers. The pharmaceutical industry is very wealthy. Those who supplied contaminated products are guilty of gross negligence and the Department should pursue them vigorously.

I share with other Senators a deep sympathy for the families of those who died. Many who gave evidence have since died and we have a great responsibility to them.

I thank the Minister for acting on the recommendations in such an expeditious manner. He has not been found lacking and has given an enormous amount of time to an issue which no Minister would ever wish to inherit. He will continue to support the Irish Haemophilia Society and the 260 people infected with hepatitis C. As someone who served in the Department, I share with him the apology and regret expressed to those affected.

Mr. B. Hayes

I welcome the Minister to the House and his comments. I wish him well in the continuation of his work.

This has been a good and full debate and the comments on all sides have reflected the enormous tragedy of this entire episode for the country, the Department and the Irish Blood Transfusion Service over the past ten years. As Senator McHugh said, while this is not a party political issue, people expect politicians to respond to the tragedy as best they can. The comment by Senator Leyden about the former leader of my party, Deputy Noonan, is absolutely accurate. Deputy Noonan has been kicked around unfairly. A considerable amount of abject party politics were played in relation to his performance as Minister. I remind the House that he put in place a compensation mechanism to begin to deal with all of the victims. I regret very much the way he has been badly tarnished by this debate. I say that as a fellow member of his party and I recognise the comments made by Senator Leyden. Deputy Noonan was unfairly made to carry the can for mistakes that were made in areas over which he really had no control. That was wrong and we should be courageous enough to say so. It should not have happened.

Probably the most important issue for the Minister or any other Minister for Health and Children is to ensure the integrity of the Irish Blood Transfusion Service. If people do not have faith in that institution, they will not give blood. It is absolutely essential in any modern health service to have in place a blood service which is beyond reproach and in which people have confidence. If we have learned anything from the events of recent years, it is that the confidence of the public has been dented. I welcome the Minister's initiative to rebuild and re-establish faith in the Irish Blood Transfusion Service in order that people will readily give blood, which can then be used in vital operations.

I wish to make a particular point in respect of the report by Judge Lindsay. The report has been kicked around in this House, the Lower House and the public arena since it was published. I sometimes think we gave the judge an impossible task. It is easy for politicians and commentators – people who did not attend all of the tribunal's sittings and were not obliged to weigh up the evidence presented – to castigate some of the findings of the report. I do not say that we gave the judge an impossible task by way of defending her. However, where issues of this nature have to be determined, it is important that we, as politicians, should take some responsibility. That is why I favour parliamentary inquiries and the sooner the better we move to introduce a system of parliamentary accountability where important issues of this nature are determined upon in the House by groups of Senators and Deputies. This would be a much more constructive way to investigate matters of this kind.

It is easy for us to read the report and its recommendations and then reach a conclusion. We were not present to hear or see every item of evidence presented to the tribunal. It is too easy to attack someone who is not here to defend themselves, as has happened, unfortunately, in both debates, although much less so here than in the Dáil. If we are going to initiate investigations of this sort in the future, the model we should put in place is that employed during the investigation into DIRT, namely, a parliamentary inquiry. In that way, we would have some ownership in terms of the recommendations and actions that would flow from such an inquiry.

As the previous speaker stated, the report has been referred to the DPP which is a welcome development. However, I would caution people in respect of this issue. The DPP is entirely independent of the Minister and the Government, and rightly so. If charges are to be preferred against any of the individuals or bodies concerned, that will happen in due course. However, we should not act as judge and jury until such cases come before the courts. We should be extremely cautious about tribunal reports where, as the previous speaker indicated, a judge has to make extremely difficult decisions and reach conclusions. We ask a person to carry out an inquiry and when they issue their recommendations, we either accept them or reject them according to the political mood that is abroad. That is very dangerous. I caution Members and the public at large in respect of evidence they have not heard.

Ms White

I wish to make a number of brief comments. I commend the Minister on the speech he delivered earlier. He dealt with the Lindsay report and the action he intends to take in a fulsome and satisfactory manner. I compliment him on the fact that he remained in the House for the entire debate and did not leave when he had made his contribution.

Mr. B. Hayes

Hear, hear.

Ms White

As a new Member, I find it disturbing to see Ministers coming and going during debates. I thank the Minister on behalf of all those who suffered for remaining in the Chamber for the debate. I also compliment him for apologising many times during his contribution on behalf of the State for what happened to the people who died and to the families who suffered distress.

This is the most serious, shameful and dishonourable scandal since the foundation of the State. The Flood and Morris tribunals pale in significance in comparison. There has been a great deal of gossip and discussion in the public arena about cash in brown envelopes in respect of those two tribunals. However, I do not believe this scandal attracted much public attention other than among the members of the families involved.

I speak today in order to help ensure that a scandal of this nature is never allowed to happen again. As legislators, this is our grave responsibility. What we must do now is implement some practical, but nonetheless essential, steps to ensure that there is no recurrence. The board the Minister has established must be charged with responsibility for the treatment and care of persons with haemophilia. Included under this remit should be the responsibility for ensuring that the blood products used in Ireland are of the highest standard. The board should also be able to provide for a regular external audit of haemophilia centres.

A number of grave mistakes were made. We need to ensure that the problems to which they gave rise are rectified. A sufficient number of consultant haematologists should be appointed throughout the country to increase access for persons with haemophilia.

From personal experience I am aware that the victims and families under pressure during the period of this tragedy received little support from the State. It was the Irish Haemophilia Society which provided counselling, home help and financial assistance to these families in their desperate hour of need. There was no one else around to help. The Irish Haemophilia Society needs ongoing financial support to continue providing professional aid and assistance. The State should commit itself to providing support for counselling, financial assistance, practical assistance and guidance.

In my opinion the Lindsay report is couched in flawed language. Nobody has been brought to task for this. I was surprised that previous speakers justified Judge Lindsay's position and made excuses for her. I do not hold with that. A judge charged with presiding over a tribunal should be given a job specification and told what they are required to do and what is expected of them. As Senator Feighan stated, 79 people have died and many hundreds of others are living with a time-bomb. It is for this reason I support the decision to refer the report to the DPP.

The Minister for Health and Children should fulfil his commitment to inquire into the origin of blood products during the period in question. A television programme on RTÉ on Sunday night stated that they were manufactured from blood donated in US prisons and by people there with HIV. The Minister must take responsibility for inquiring into the role of international pharmaceutical companies in this scandal.

I wish to reiterate that I cannot agree with Members on both sides of the House who sought to justify Judge Lindsay's report and who seemed to exonerate her. I do not hold with that. A person holding such a senior position should be well able to determine and should have the courage to indicate where the responsibility lies.

Minister for Health and Children (Mr. Martin)

I thank the Senators who contributed to this important debate on the Lindsay tribunal's report on what has been a most traumatic and appalling event in the history of Irish health care and for the haemophiliac community.

The tribunal has had a deep impact on the public consciousness. I am aware the report has generated much disappointment and anger but what will live in the memories of many people is the personal testimonies presented to the tribunal which were relayed faithfully in the national media, and RTÉ in particular. Paul Cunningham has done an enormous amount of work in terms of bringing the work of the tribunal to the public audience via the television medium. Other television channels and radio stations, Today FM and others, have focused significantly on the work of the tribunal and the issue involved. I have decided to publish the personal testimonies as a memorial to those who were brave enough to come forward and give evidence in what must have been very difficult and traumatic circumstances for them.

There were a significant number of contributions to the debate. A number of Senators referred to the methodology by which we should investigate issues such as this and whether the tribunal model is the best one. Senator Brian Hayes raised that issue and it is one that the Oireachtas and the Government should return to again in the future. I will return to it at a later time in a different debate. We should accept that there is no one model which is best equipped to deal with the variety of issues currently being dealt with under the 1921 Tribunals of Inquiry Act. The reflex action is to refer to the 1921 Tribunals of Inquiry Act which has many limitations, particularly in areas of health.

Mr. B. Hayes

That is right.

Mr. Martin

I share the views of some who believe we should opt for a more permanent type of statutory based investigation forum or whatever to investigate issues that require investigation as they arise from time to time in the public arena.

We should remember also that every time we set up a tribunal, it is an indictment of existing agencies set up to investigate matters in the tax, criminal or health areas. These agencies are supposed to find out what, why and how something happened in a particular area. Senator Brian Hayes made the point about the criminal investigative model and said that ideally tribunals should be involved only in examining systemic failure and how we can learn lessons for the future. There are different models, therefore, and we have to try to move away from the one model.

I take Senator Brian Hayes's point about our response to the tribunal report. I have been careful in my response to the report because I am concerned that we may now judge reports on what we think they should contain.

Mr. B. Hayes

Exactly.

Mr. Martin

I articulated the point on a radio programme yesterday that it is almost a case of wanting to know the end result of a tribunal before it has reached its conclusions and if we do not agree with them, there is something wrong with it. That is not to take in any way from some of the genuine critique that has been articulated in the House but it is something about which we must be careful. We cannot have judge, jury and execution before a tribunal has even reported. Otherwise, we will undermine the whole process from the beginning. It is meant to be an independent process and once the Oireachtas establishes the creature that is a tribunal, we are at the mercy, to a certain extent, of both the way it works and the efficacy of the body itself and the personnel involved. We set in train an independent process and it reports back to us with its findings.

I agree with the idea of a convention as to how reports should be presented. Reports should have executive summaries and there are important issues about the organisation and presentation of reports.

I take Senator Minihan's point in that the Lindsay report is critical of various people. If I were in the shoes of certain individuals reading the Lindsay report, I would be distinctly uncomfortable. The Department of Health and Children, the BTSB and medical professionals come in for significant criticism in the report. The language may be different from other reports but Senator Minihan made the point that we should not misinterpret some of the language either. Certain pictures emerge from the report in terms of what went wrong, and certain people could not contribute to the report and give their knowledge of what happened because they are no longer alive.

The terms of reference were quite broad, with the exception of the dimension of the international pharmaceutical companies. My predecessor, Deputy Cowen, was involved in the work leading up to the establishment of this tribunal and it took a considerable length of time before the terms of reference were eventually agreed upon by the Irish Haemophilia Society and the Government of the day. I accept the IHS had reservations but, nonetheless, its members felt that the terms of reference would encompass an investigation of international pharmaceutical companies. On examining the terms of reference, one would have to come to the conclusion that they do not explicitly state that we should pursue the pharmaceutical companies but they allow for that in terms of the elasticity of the terms of reference, if one wants to interpret them that way. The judge, in her wisdom, decided that this area did not fall within the terms of reference and when I made a request late in the day, she made the reasonable point that if she changed the terms of reference at that late stage, she would invalidate the process for some participants. That was the judge's conclusion and I will come back to that in a moment. In almost all other areas the terms of reference were broad enough and I do not believe Ms Justice Lindsay lacked any of the mechanisms available to Mr. Justice Flood. They were both free to make conclusions at the end of their investigations.

The recommendations are sensible. They are not earth-shattering and one wonders why some of them are not in place. I stress that the word "supports" in the Government motion before the House is not self-congratulatory or meant to be a clap on the back for anybody. It is merely to record in this House – this aspect did not cause any division in the other House, which is normally more adversarial – that we acknowledge the extraordinary suffering of those people with haemophilia who were infected, and their families. The word "supports" appears to have thrown Senator Ryan and others.

One paragraph supports the referral of the report to the Director of Public Prosecutions, with which everyone agreed. There should not be any conflict in that regard. There is also a reference to the Government's commitment to implement the recommendations in the report. We are seeking the support of the House for that and that is the only context in which the word was included. We are seeking the support of the House to implement the recommendations and, more importantly, to set up the National Haemophilia Co-ordinating Committee, which is a recommendation of the report and which the Irish Haemophilia Society strongly supports. I met the members of the society before putting resolutions to the House and they asked that certain items be included, and particularly this item. They did not ask for support but they wanted the item concerning the national co-ordinating committee included.

There is also an acknowledgement of the high standard of care because it is important that we acknowledge the difference in terms of the services now available, particularly in the National Centre for Hereditary Coagulation Disorders, previously the National Haemophilia Centre, which has now been modernised. It is a fantastic facility and ground-breaking research of international significance is being carried out in the centre, which we should acknowledge. It is important to lift the morale of the people currently working in this field because it is probably one of the more difficult areas.

The Government has given an undertaking to work in partnership with the Irish Haemophilia Society and treating clinicians to ensure the highest standards. That is significant because when all of this started in the 1980s, there was not that type of co-ordination among clinicians, the consumers of products and the Government but we are all in this together. From now on there will not be anybody arbitrarily selecting products on their own. We set up a blood products group over a year ago on an ad hoc basic and we are committed to doing that on a statutory basis. Again, we are working with the Irish Haemophilia Society.

Last year we were faced with decisions when a major problem arose in one of the companies which manufactures the recombinant or synthetic blood products. We were suddenly faced with a shortage of those products, which meant we had to contemplate moving back to blood derived products. Where was the source for those blood derived products? The United States. That is because it is the one country that does not have BSE or CJD.

That demonstrates the dilemma we were faced with and, therefore, we had to take collective decisions to make sure that children would receive priority whatever blood product was available. It is far better that nowadays these decisions are being taken collectively with everybody having full access to knowledge concerning the risks that are presented. That is all we are asking in terms of the motion which, among other matters–

supports the Government's commitment to ensuring the availability of an adequate and ongoing supply of clotting factor concentrates that meet the highest national and international standards of safety and efficacy.

I agree totally with what Senator Ryan said about the responsibility of board members. The most difficult and challenging board to join today is the Irish Blood Transfusion Service. Quite frankly, one would want to think twice before going on that board and I am saying that having asked people to join it – and they accepted. The board's members have to be careful and cautious; they have to inform themselves and think of the future.

One of the pressing matters coming down the tracks is the transmissibility of variant CJD. A question has been raised as to whether or not to defer surgery for that part of our population who lived in Britain during the critical incubation period of that disease. If we did so it could have a major impact on life-saving surgery. We are continuing to review that matter. There have already been some deferrals and there may be a need for more. The other side of the equation is to make sure there is an adequate blood supply to save lives today and so the story moves on. We have a national CJD advisory committee that continually advises on these issues, and we are also working with the IBTS.

When I read the Lindsay report I asked myself the same questions that Senators have posed, including what was known about the heat treatment of products at the time. We must now ask ourselves the same type of questions concerning the transmissibility of CJD and the future risk to the population.

Senators Glynn, Feighan and others referred to the investigation of pharmaceutical companies. I will sound a note of caution as I do not wish to mislead the House in any way. I commissioned Mr. Paul Gardiner, senior counsel, to undertake a study on this matter. He has now completed his report, a copy of which I have sent to the Irish Haemophilia Society for its perusal. There are issues involved which, obviously, would impact on an inquiry. We are committed to pursuing the pharmaceutical issue but in so doing we would be moving into extra-jurisdictional territory involving profound legal issues. Senators will be aware that there are difficulties involved but, notwithstanding that, we intend to pursue the matter in consultation with the Irish Haemophilia Society.

I met Mr. Gardiner this week to discuss his report and I will be meeting the Attorney General shortly. Following that I will be meeting the Irish Haemophilia Society and will then be reverting to the House with a template for progressing on that issue. I do not wish to understate the fact, however, that there are significant obstacles.

Senators Terry, McHugh and Leyden raised the issue of funding. The current funding for the Irish Haemophilia Society is about €300,000. The society had ongoing needs and sought an extra €300,000 to which I have agreed. That is the current position and it is mainstream funding. In May, we negotiated a significant compensation package for haemophiliacs and we amended the Hepatitis C (Tribunal of Compensation) Act to encompass them. While we broke with legal precedent, I was happy to do so. It represented an unprecedented departure from the normal laws of tort, particularly as it allows bereaved families to claim on the same basis as a living claimant. In fact, it is more complicated than that but, in recognition of the uniqueness of this tragedy, I was quite prepared to break legal ground and depart from the normal kind of advice one might receive in such situations.

I accept the important point made by Senator Feeney, that it is disquieting and unsettling that the victims, members of the Irish Haemophilia Society, have not found solace in this report. That refers back to my point that it is important not to raise expectations too high as to how we can move forward on this issue. We can, however, take initiatives that will provide increased solace to the victims and particularly to the families of the deceased as a result of this scandal.

I think I have covered most of the issues raised by Senators. More work remains to be done, including the appointment of extra haematologists. Although we have improved the position dramatically we have to make sure that the various centres across the country are of a sufficiently high standard.

Senator Leyden made a point relating to a committee of which he is chairman and my understanding is that all relevant documentation was discovered to the tribunal. I do not know the exact title of Senator Leyden's committee but we can check that later and I will refer back to him about it. It is important to make the point, however, that all documentation was discovered to the tribunal.

I thank you, a Leas-Chathaoirligh, and all the Senators who contributed to what has been a very effective debate.

Question put and agreed to.

Sitting suspended at 5.10 p.m. and resumed at 6 p.m.

Seanad Éireann debate - Wednesday, 13 Nov 2002