Dáil Éireann díospóireacht -
Wednesday, 6 Nov 2002

Vol. 556 No. 4

Lindsay Tribunal Report: Motion (Resumed).

The following motion was moved by the Minister for Health and Children on Wednesday, 23 October 2002:

"That Dáil Éireann:

notes the publication of the Report of the Tribunal of Inquiry into the infection with HIV and hepatitis C and HIV 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 sub-committees, 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 healthcare continue to be made available; and

supports the Government 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."

Debate resumed on amendment No. 2:

To add the following to the motion:

calls on the Government to initiate the promised inquiry into the relevant international pharmaceutical companies; and

supports the provision of adequate funding to the Irish Haemophilia Society on an ongoing basis to allow the society to fully represent the interests of people with haemophilia."

–(Ms O. Mitchell).

Ms McManus

At the outset, I express my regret for any offence I may have caused to people who have suffered so much.

I was outlining the difficulties concerning the truth as regards the board's role and its responsibility for factor 9-related HIV infections, or its knowledge of same. Neither chairman nor board members were called to the tribunal to settle this central issue. Instead, the tribunal chairman, Ms Justice Lindsay, took it as fact that the board did not know and, therefore, this information did not come to the Department of Health, which led to the Minister for Health at the time, Deputy O'Hanlon, giving misleading, inaccurate and incomplete information to this House, albeit unwittingly.

It is reasonable to expect that such a chain of events would have been the subject of scrupulous attention and investigation by the tribunal. The haemophiliac community was poorly served by this failure and so was this House. We have a right and a duty to know when a serving Minister was led up the garden path, intentionally or not, and, as a consequence, misled the public who are represented in this House. It is up to the Minister for Health and Children to investigate this matter further. He should appoint a senior counsel to go through all the documentation with the full compliance of the BTSB. If there is any non-compliance he should take immediate action, and I look forward to his reply to this particular request when he responds to this debate.

We do not have answers concerning the conflict of interest in the role of Mr. Seán Hanratty, who was a member of the board and yet, at the same time, a company director of Accuscience, a company responsible for importing factor 8 concentrates into this country. Furthermore, there was no thorough investigation into his destruction of documents, which not only created obstacles for haemophiliacs taking legal action, but also led to the finding of the tribunal that 20 people have remained untraced who may potentially be infected by HIV. That inability to trace these people stems directly back to the destruction of records. Their untraceability may well mean that more illness and death will result from this desperate saga.

We have to commend all those victims who were courageous enough to speak at the tribunal. Their testimony, more than anything, is a central part of this process. We have to ensure that the Minister for Health and Children finishes the work that should have been taken up by the tribunal chairman, that is to investigate the role of international pharmaceutical companies. Her decision not to extend the terms of reference was most regrettable. In fact, her statement at the early stages on this issue was essentially that it was too early to make a decision on whether to investigate these companies' roles, and later she refused to do so on the grounds that it was too late in terms of the proceedings of the tribunal. I do not believe that she was restricted by the terms of reference. She clearly did not wish to embark on that part of the project as her refusal to accept the Minister's suggestion indicates.

It is now vital that, whatever form this investigation takes, the lessons learnt from this process are applied and mistakes are not made in the same way. The international pharmaceutical companies are important. For example, the report does not deal with the role of Armour Pharmaceutical Company in respect of its defective heat treatment process. One Irish child died as a consequence of an Armour product, yet the report is silent. An expert witness, Dr. Francis, talking at the tribunal about the role of international companies stated: "What they did was eliminate a whole generation of haemophiliacs who indeed needed their products".

I commend the media for its role in highlighting the issues affecting Irish haemophiliacs. Television programmes like "Bad Blood" made a real and significant difference and the coverage over the years by the media was essential to exposing the nature of the catastrophe. Great hopes were pinned on this tribunal, and great effort was put in to make it live up to its possibility. Sadly, the outcome has not lived up to the expectations. As we can see all around us, dark, painful and important secrets about Irish society are being revealed. However, the full truth has not yet been told about the contamination of blood products and their impact on Irish haemophiliacs. It is a matter of deep regret and it is a fact that must not be forgotten. We should all strive to ensure that whatever can be done is done to provide the closure and ease of mind that the haemophiliac community so richly deserves.

I hope that the Minister and the Oireachtas Committee on Health and Children, the chairman of which I will be writing to in this regard, will pursue the unanswered questions in the report. Clearly, the Oireachtas committee is limited, particularly in light of court decisions, but at the same time it provides an important democratic forum where these issues can be further explored.

I ask, as does the Irish Haemophiliac Society, that the Minister for Health and Children take on the specific issues concerning the role of the BTSB in respect of its responsibility as regards the infections caused by factor 9 and that he appoint a senior counsel to be given the brief to survey and assess all the documentation, because not all the documentation came to the tribunal. Documentation was withheld, not by the Minister but by the board. Nevertheless, the Minister appoints the board and he is in a powerful position to ensure that all that information comes into the public arena.

I would like to ensure that we proceed with this work rather than presume that, because the tribunal has sat, that represents inevitable closure on the issue, because there is grave dissatisfaction and disappointment regarding the lack of conclusions and findings in the report. It is inconclusive in many ways although, having said that, it is also an important report and its value lies to a great extent in the record of events that took place, particularly the testimonies of individual people who were brave enough to come forward.

At the outset, I expressed my regret for any offence I caused. It is the last thing in the world I wanted, and I wanted to put on the record that any assistance I can give in the future to people who have suffered will be very heartfelt.

Ms Sexton

On the scale of public scandals in this country to date, the provision of infected blood by a public service body, the BTSB, has to rank as the gravest. This State-sponsored catastrophe is widely accepted and agreed to have led to the deaths of 79 people. In view of this, the conclusions of the Lindsay tribunal are, to say the least, disappointing in the extreme.

This ostensibly expert body entrusted with central purchasing and distribution of blood products in Ireland had an ethical and moral duty to ensure that all necessary measures were in place to protect haemophiliacs, a vulnerable and innocent group of people. The gross negligence displayed by the BTSB has caused, and will continue to cause, untold pain and suffering to the victims and their families for many years to come. Not even the most rudimentary ethical and commercial practices were followed when guarantees or assurances of any kind were neither sought from, nor given by, the companies supplying the product.

I do not agree with the tribunal finding that because of prevailing opinions and practices, the BTSB should not be criticised for continuing to import and distribute commercial concentrates while aware of the risk of transmission and infection by these products. We all, as individuals and groups, have individual and collective responsibilities on matters of this nature and it is incumbent on all of us to act swiftly when we receive information that might adversely affect life. It is our moral duty to ensure that action is taken immediately to minimise the risk to life.

In line with the policy of self-sufficiency regarding the provision of blood and blood products which existed in the early 1970s, the report makes reference to the heparin project. Essentially, this appears to have been an experimental project which drifted from year to year without any evaluation or assessment as to its progress or usefulness. This calls into question the management of the BTSB and its ability to take decisions at all.

The inability of the BTSB to respond to matters of urgency drawn to its attention is clear. When in January 1985 it was asked to give urgent attention to heat treatment of all products, this did not happen until October 1985. In fact, non-heat treated factor continued to be used by it until December 1985. Such delays and negligence contributed to and were, the report concludes, the most probable cause of seven people who had hepatitis B becoming infected with HIV. This further lack of control was evident when the BTSB did not even pursue the possibility of entering into partnership with suppliers who could have provided concentrate that had been effectively inactivated.

Self-sufficiency was the policy of the BTSB. The tribunal asserted that the lack of capital resources did not inhibit the achievement of this policy, therefore, the conclusion is obvious. The pursuit of the ideal sponsored by the board proved to be non-viable and was gravely erroneous. While I agree with the tribunal that if capital funding had been provided by the Department of Health and Children it might have allowed the time and energies of the BTSB to be confined to medical and technical matters, the provision of such funding would not necessarily have been successful because the management structures within the BTSB were such that there were no guarantees as to how this funding might have been expended. It might have been squandered in the pursuit of the ideal of self-sufficiency.

The findings revealed by the tribunal were not confined to Ireland. There were many blood scandals throughout Europe. The French experience comes to mind most readily where criminal prosecutions and custodial sentences were imposed on those deemed to be culpable. Early last year I contributed to the development of a common opinion at European Union Committee of the Regions level regarding a proposal for a directorate by the European Commission for setting standards of quality and safety for the collection, testing, processing, storage and distribution of human blood components. In proposing such a directive the Commission acknowledged that the existing Union legislation did not comprehensively deal with standards of quality and safety in blood product matters.

I am confident the new legislation will soon be implemented here through statutory instrument. It will close the existing gaps in Union legislation and provide a suitable legislative framework for the quality and safety of blood and blood components used in therapy and will strengthen requirements related to the sustainability of blood and plasma donors and the screening of donated blood. It will set up at member state level requirements for the establishment involved in the collection, testing, processing, storage and distribution of whole blood and blood components as well as national accreditation and monitoring structures. It will lay down provisions at Union level for the formulation of a quality system for blood establishment and will provide common provisions at Union level for training staff directly involved in the collection, testing, processing, storage and distribution of blood and blood components. It will establish rules for the traceability of whole blood and blood components from donor to patient, which will be valid throughout the Union.

While significant improvements and programmes have been put in place to support the reorganisation and redevelopment of the service in Ireland, the further addition of this European Union legislation will complement and strengthen them. There is a need to regulate and inspect the application of appropriate standards in Ireland and throughout the European Union. The new EU directive will ensure that the standards envisaged will always reflect best established practice and will not allow member states to fall behind.

For public confidence to be restored in the BTSB it is vital to ensure that the highest standards are maintained. I am pleased that when he spoke last month the Minister reassured the House of his intention to refer the tribunal report to the DPP where I hope and expect action reflecting the serious nature of this gross negligence will be recommended to the relevant authorities. While all of these matters are of scant consolation to the many victims and their families, it can only be hoped that what is now being pursued might lead to the prevention of a recurrence of a tragedy of this nature.

Mr. Neville

I welcome the opportunity to contribute to this important debate, one of the most important on the health issue to be held in this Chamber because of the implications of the difficulties experienced by a small group of citizens. I support the Fine Gael Party amendment, proposing to add to the motion a call on the Government to initiate the promised inquiry into the relevant international pharmaceutical companies and support the provision of adequate funding to the Irish Haemophilia Society on an ongoing basis to allow the society to fully represent the interests of people with haemophilia.

The issues dealt with by the tribunal concern one of the biggest medical catastrophes to have occurred since the foundation of the State. On reading the reports of the sitting of the tribunal, one could not fail to be shocked, deeply moved and upset about what happened to members of the Irish Haemophilia Society and the fact that 260 people and their families were deeply affected, with their lives practically destroyed. An effort should be made to put oneself in the position of somebody who was visited by such an event to try and understand the extent of the catastrophe. Given that 79 people died from contaminated blood products, the Lindsay tribunal was probably the most important of all the tribunals established in recent times.

We are concerned here with life, death and human suffering and the effect on those involved, their families, brothers, fathers and children. We have all experienced tragedy in families but it is another matter to be visited by tragedy in this fashion. Those concerned fully trusted the system to deal with their condition and it is difficult to describe the extent of the catastrophe of their betrayal.

I congratulate the Irish Haemophilia Society for the work it has done and for the way it facilitated witnesses to the tribunal. The reports of the tribunal sittings revealed people who were deeply traumatised, to such an extent that they found it very difficult to present their evidence to the tribunal. They felt they could not reveal their names, which is surely a strong statement about the problems they experienced.

I thank the Irish Haemophilia Society for the excellent briefing it provided to Members of this House. It was very helpful in the context of reading the tribunal report. The society has made clear in writing that it is very disappointed with the report, which, it maintains, largely fails to identify those who were responsible for what happened. I support that view and while a political view is one thing, this is the view of those who suffered.

The society also refer to the manner in which witnesses from the BTSB were allowed to depart from their prepared statements while those with haemophilia who delivered personal testimony in such an emotional and difficult way were required to strictly adhere to the content of their statements. If they deviated in any respect from their written statements, senior council on behalf of the tribunal objected. I am at a loss to know why people were not allowed to freely give their views. We all know the difference between a written statement, which is historical in nature, and the spoken word. Why were the witnesses not allowed to add to or qualify some of their remarks?

As the haemophilia society stated, such testimony is by its nature very emotional, bordering in some cases on the distraught. Those giving evidence had grave difficulties with the manner in which the tribunal dealt with their personal disasters. Surely the tribunal's job was to obtain the truth of the information presented to it. Why were the witnesses not allowed to express, in their emotive distraught fashion, how they felt in giving their evidence? That must have significantly added to the trauma those people had already experienced in their lives. It required great bravery on their part to go into the tribunal in the first place to give evidence, yet the tribunal's attitude to them was very inhuman.

The haemophilia society is extremely concerned about the failure of the tribunal, as it sees it, to undertake a proper and comprehensive investigation. It also expresses concern at the failure of the tribunal chairperson to deliver a report in a clear and concise manner which indicated what went wrong, who was responsible for such wrongdoing and how recommendations could be implemented to prevent future repetition of such mistakes. Surely they were vitally important questions that should have been part of the summary. We have seen other reports that were concise, detailed and to the point, whose first pages contained details of the core issues surrounding the tribunal investigation. That did not happen in this case. People with haemophilia required from the Lindsay tribunal report evidence that a full investigation had occurred. Regrettably the report failed to achieve such an objective. That is not only my view but that of the Irish Haemophilia Society.

Why was the tribunal reluctant to investigate certain matters and call all witnesses relevant to it? The haemophilia society referred specifically to the absence of witnesses such as various Ministers for Health who had ultimate political responsibility for policy decisions such as the non-implementation of a national policy in respect of European Council recommendations. In addition, a later Minister for Health refused the request of the Irish Haemophilia Society for recompense and compensation for their members. No board member – this has been central to some of the criticism with regard to the taking of evidence – was called to deliver evidence, although the Irish Haemophilia Society suggested it on numerous occasions in written correspondence. It would have been appropriate to do so, as it would have resolved some outstanding issues.

It is crucial to the haemophilia society's desire for truth and justice that the Minister for Health and Children immediately follows through on his commitment to ensure there is a comprehensive inquiry into the international pharmaceutical companies who criminally exposed the lives and safety of people when they knew the inherent dangers.

Ms F. O'Malley

I am glad of the opportunity to speak in this debate, but my appreciation does not extend to the report of the Lindsay tribunal itself. A valuable role of the tribunal is that it has offered a forum to the victims of this appalling litany of negligence to finally be heard, but is this the best that the inquiry can offer those victims?

The failure of Ms Justice Lindsay to apportion blame or responsibility is disappointing and for those who have borne their pain, anguish and suffering in such a dignified manner, frequently under such hostile cross-examination at the tribunal. Having fought for so long to get the inquiry set up it is all the more disappointing that the report gave rise to more questions than it answered. This has given rise to fury in many instances. I am glad the Minister for Health and Children, who has direct responsibility for this issue, has decided to send the report to the DPP, despite the reluctance of Ms Justice Lindsay to advise him of that. It is important that whoever is responsible for the deaths of 79 people stands accountable, that a scandal of this magnitude never occurs again and that rather than find ourselves at the end of a process we are merely at the beginning.

Previous speakers have adverted to the experience of France where crimes against the State were punished with prison sentences. As has been said by many tribunals that have reported back to this House, it is a measure of our maturity as a democracy how we respond to criticisms and failures of State systems. I believe the action announced by the Minister to send the report to the DPP reflects the seriousness with which the Government views this scandal. I imagine the report will receive the diligent attention of the authorities. Where there was a wrong done it must be righted. I believe this House is unanimous in its quest for justice in this matter.

In the early 1980s, which is the period being investigated by the tribunal, AIDS was a scourge with which we were becoming familiar and it remains a most devastating disease. There was an element of groping in the dark in regard to the treatment around it. At that time it was seen as a disease which blighted the gay community but as we have since discovered that is not necessarily the case. With regard to its transfer through sexual contact the message of "safe sex" was very clear. For haemophiliacs there was another clear message "safe blood". It would appear a sentence needed to be added to that – safety, honesty and rigourousness from State agencies.

Mr. Ring

I am delighted to get the opportunity to make a few short observations in regard to the Lindsay tribunal report. We have had many tribunals and most of them have been in regard to corruption but no deaths were involved. This has been the greatest scandal that ever happened in this country. I was disappointed with the report's failure to identify the guilty parties.

On the day the tribunal was set up by the Minister at the time, Deputy Michael Noonan, I was the next speaker for Fine Gael to speak after him. I stated in my contribution to that debate that I hoped there would be an inquiry and at its conclusion the people who were responsible would end up in Mountjoy Prison. While the Minister is not fond of prisons, it is wrong that people who were identified in the report and who displayed arrogance towards the tribunal are still walking around when many a son, daughter, husband, wife, brother or sister has lost a loved one because they are in a graveyard. That is the greatest scandal. The other scandal is the media gave a great deal of coverage to the other tribunals even though not one life was lost. The loss of life and the suffering of loved ones resulted in this tribunal.

I hope the DPP will act on the report. If the Minister feels the DPP cannot act on it and that the matter should be taken further through criminal prosecutions taken by the Department of Health and Children against the individuals responsible, that should happen. They should not walk away free because this is such a scandal nor should they be allowed to walk away free because they worked in the Civil Service and in hospitals. They should not be protected by the State or anybody else. This has been the greatest scandal in the State's history because people lost their lives. This issue must not be hidden or brushed under the carpet because those who were responsible were part of the institutions involved and they must be dealt with.

I refer to another group of people about whom I wish the Minister to respond. I am aware of the case of one of these people, who resides in my constituency. The Acting Chairman is a doctor and he is also aware of this case. It and others involve people who received contaminated blood transfusions and displayed all the symptoms of hepatitis C. When their blood was tested, the disease did not show up. What can be done for them? They feel they are being pushed aside by the State and medical professionals and nobody will fight for or defend them. We know they received contaminated blood products and have been affected but the infection does not show up in the hepatitis C blood test. I ask the Minister to re-examine the cases involving these people, to show them a little compassion and that somebody cares about them and to ensure they will not have to fight like we did in the Oireachtas to get the Lindsay tribunal up and running. These people seek recognition of their problem and medical help, not compensation.

A lady came into my clinic who had received contaminated blood products and for the first time in my life in politics I cried. She had gone through the health system. She met all the medical professionals involved and at the end of the day they tried to imply that she was not keeping well in her head. This poor woman received contaminated blood and when she did the hepatitis C test, the disease did not show up. She is upset, as is her family. She displays all the symptoms of the disease and is in very bad health as she has gone from one illness to the next. The Minister should re-examine the cases involving people who were affected this way and perhaps down the road in ten years we will discover they were infected. I hope they can be given the sympathy they need.

I hoped the report, similar to the Flood tribunal report, would highlight who was responsible for this scandal and that they would be dealt with in the Four Courts. The families of the victims feel hurt, let down and that the State has not done its duty. Are those responsible being protected because they work for the State? If they were ordinary Joe Soaps, they would be identified and prosecuted. My blood boiled when I witnessed the arrogance and defiance they displayed at the tribunal. Those who were responsible must pay a price and justice must be seen to be done. While the families do not want people sent to prison, they want those responsible for this national scandal to be identified. They do not want this scandal brushed under the carpet.

The State has done a disservice to the families who have lost loved ones. The victims entered hospitals expecting to be cared for by the State. Those who were responsible for the scandal were recruited and paid by the State in good faith. However, there is no doubt there was a cover-up because people knew what was going on. At the time, as was pointed out at the tribunal, certain individuals should have stood up to be counted and spoken out because some lives might have been saved. I hope there will be prosecutions and that the people who knew what was going on are put in jail and pay a price. We cannot bring back the loved ones of the families involved in this national scandal. What happened was the greatest disgrace in the history of the State. Our own citizens were infected and those responsible must pay a price.

The Ministers for Health and Children and Justice, Equality and Law Reform are present and both are strong Ministers. I hope they will ensure justice is done quickly because if somebody is not identified as being responsible, then there is a cover up.

Dr. Devins

I welcome the contents of the report and I commend Ms Justice Lindsay on the speedy resolution of her work. She presented a report within three years of being authorised to do so and perhaps the other tribunals could learn from that. Haemophilia is a serious, genetic condition caused by a problem with Factor 8 in the clotting mechanism in our blood and Factor 9 in Christmas disease. While the disease is carried by females, it is manifest in males and because of its genetic make up it tends to occur in families. The distress and anguish caused by the disease is worsened because it affects entire families.

Such families in the past had a close working relationship with their medical advisors and, in many cases, had built up trust. The health system exists to help people and the most important person in it is the patient. The BTSB is an important part of the health system and during the period that the report covers the board did not deliver. Unfortunately, in giving blood to patients at the time, they were in effect giving them a loaded gun and that proved fatal in a number of cases. As I read the report I was struck time and again by the severe anguish and stress that patients suffered for a multiplicity of reasons, not least of which was deaths in their families. However, there were other reasons for their distress.

Ms Justice Lindsay stated in the report:

There was an abiding sense of hurt, anger and resentment as a result of their experiences with health professionals. I found the evidence at times sad, at times tragic and at times harrowing.

This hurt was all the more distressing because of the close relationship that had been built between the patients and health professionals involved. It is not good enough that information in some cases was delayed as regards the status of patients' health. In some cases that information was transmitted to the patients or their relations in an unsympathetic manner and in corridors or other unsuitable places.

We should spend time looking at the recommendations of the report because that is where the future lies. I note that in 1996 there were 15 haematologists in the country. Today there are in excess of 33. That was one of the recommendations of Ms Justice Lindsay. She spent a lot of time talking about medical records. As those of us who worked in the health care field know, much time is spent taking a patient's history, examining the patient and making a diagnosis. However, the same time should be spent writing up what one has found. In this case and in the cases outlined in the report there was a deficiency in the medical records. That must be corrected in the future because it hampered the work of the tribunal to a certain extent.

The Irish Blood Transfusion Service, which was called the BTSB, has regained the faith of the people. That is good because the health service needs blood and patients must have full faith that the blood they get is of the highest possible standard. I recommend to the Minister that an external audit should be carried out by a consultant haematologist every year for the coming years to ensure that the blood patients get continues to meet the standards they deserve. That would help to develop faith in the Irish Blood Transfusion Service in the future.

I welcome the recommendation to set up a national committee. I would warmly welcome the Minister's decision to establish it. I know he is in ongoing discussions with the Irish Haemophilia Society about the structure of that committee. It is important to put it in place to ensure the availability of an adequate and ongoing supply of clotting factor concentrates which meet the highest possible standards in terms of safety and efficiency. I welcome the fact that last year the Minister set up an ad hoc committee along those lines. During the establishment process, he asked the Irish Haemophilia Society and the Irish Blood Transfusion Service to become involved. It is interesting to note that the Irish Haemophilia Society welcomed the involvement of the IBTS in the committee.

I welcome the Government's decision to refer the report to the Director of Public Prosecutions. The report clearly outlines what has happened. As previous speakers said, if blame is to be applied – in this case there must be blame – it is important that the DPP gets the report and acts on it forthwith.

Dr. Upton

I welcome the opportunity to speak in this debate. The subject must be treated with respect and sensitivity in the House and it should be above party politics. Haemophilia sufferers and their families, who were at the coalface of the tribunal, put themselves through considerable trauma in many cases by attending the inquiry. Our first concern must be for them.

The tribunal cost approximately €13 million and ran for approximately three years. Surely it is reasonable to expect value for money apart from any moral consideration of the outcome of the inquiry? It is a reasonable expectation that the families of those who died and those who continue to suffer would be given straightforward answers. Accessing that information by reading the tribunal report is not easy. Conclusions are dispersed throughout the document and it is an exercise in perseverance to try to extract the concise findings. Furthermore, and more importantly, many questions remain unanswered.

I find it amazing that no call was made to any member of the board or the chair of any of the boards to give evidence in their capacity as board members. They are not named anywhere in the report. Ms Justice Lindsay notes in her report that on the tribunal's analysis the board was not entirely blameless. If that is the case, we can assume it was in some way to blame. Why was it not asked to account for itself by coming before the tribunal and answering the appropriate questions? Is it possible we are expected to believe that those appointed to the board do not have responsibility to the public whom they represent, that they are not answerable for the day-to-day decisions made by board employees or, more significantly, that they do not have responsibility for those who suffered and died? Nobody expects that every trivial detail would be recorded at board level, but there is a clear indication in the Lindsay report that board members were aware of the practices and, more importantly, the concerns about the blood products. There were clear and unambiguous expressions of concern about some of those practices. Who are the mysterious board members that we cannot ask them straight questions? It is the absence of such accountability that gives rise to cynicism and justifiable anger.

The reference to the Ministers for Health who were described as inadvertently misleading the Dáil further compounds the issues. Who supplied the information to the Ministers and what was the basis for not providing accurate and correct information? It is not right to walk away from these questions on behalf of the victims. Were there conflicts of interest in the blood bank? What were the procedures for accessing the products and what criteria were laid down in deciding from which supplier to purchase? Was there a cash crisis that drove the board to make decisions on a wing and a prayer while ignoring the health of the people being treated?

The Blood Transfusion Service Board seemed to ignore all the signs. The scientific evidence on AIDS had been available since 1981. Hepatitis C had been recognised since 1974, although it was called non-A non-B at the time. At the most generous, it was clear that in 1984 the Blood Transfusion Service Board knew it was dealing with a high risk product which could cause infection and kill. There was an air of secrecy surrounding the decisions with no apparent accountability for the consequences. It was left to a locum doctor in August 1985 to eventually coerce, persuade and insist that the BTSB should heat treat factor 9 to safeguard against HIV infection. Despite this, the BTSB continued to supply many units of unheated product to hospitals. The BTSB product continued to cause infection up to February 1986.

The softness of the report's language defies credibility. The report does not remotely attribute a reasonable level of responsibility or accountability. The terms used are frequently woolly and meaningless and warrant a degree of scepticism. I refer to terms such as "steps should have been taken", "should have been pursued with greater urgency", "it might also be thought", "regrettable", "unsatisfactory" and "a missed opportunity". That is hardly the language of a robust tribunal attempting to establish straightforward facts when it was clear that 79 people died and many more continue to suffer. It is in stark contrast to the language used in the interim report of the Flood tribunal. By contrast, during the Lindsay tribunal hearing one judge felt it appropriate to say that the tribunal should not over-indulge a witness giving evidence on behalf of her father who had died. It appears that the language of the tribunal was open to modification depending on the person being questioned. The balance always seemed to fall in favour of those defending their actions and against those who sought answers to their legitimate questions.

The recently published Flood tribunal interim report has in many ways set a precedent for clarity and forthright conclusions. The families of those who died as a result of being treated with contaminated blood products are entitled to the same clarity. The availability of the Flood tribunal report at €1 contrasts with the cost of the Lindsay report at €10.

The role of the multinational companies and their responsibility to deliver safe products must be investigated. I accept the Minister is committed to doing that. For all those involved, that line must be pursued and those who made significant financial gain must be held accountable for their actions. How much did these companies know about the risk associated with their products? It is clear from the information available that Armour Pharmaceuticals, for example, had knowledge from three laboratories that its heat treatment method used to eliminate HIV infection from factor concentrates was ineffectual. I welcome the decision of the Minister to refer the tribunal report to the DPP. While there may have been good legal arguments for Ms Justice Lindsay's decision, it further contrasts with the clear position of the Flood tribunal.

I have identified six questions – there may be more – which need to be answered. Who supplied inaccurate information to successive Ministers for Health leading them to inadvertently mislead the Dáil? Why was no board member called to give evidence when it is clear from the report that they would have answers to some of the key questions? Will there be an inquiry into the actions of the multinational companies which supplied the blood products? I accept the Minister is committed to investigating the role of the companies and their responsibility to deliver safe products. Why did the board continue to supply hospitals with products accessed from sources that included donors from what a BTSB employee described as "skid row", thereby carrying a high risk factor? Will the Irish Haemophilia Society be provided with adequate funding to allow it to plan, organise and continue the work it has been compelled to undertake arising from the failure to protect persons with haemophilia? It is no more than natural justice that the society should at least have the consolation of knowing it does not have to depend on fundraising activities. Why is there no summary of the conclusions of the Lindsay report?

I welcome the recommendations. However, although they are clear, they are the kind of recommendations one would expect to apply to any process or organisation. As they constitute the basis of good practice, I sincerely hope one did not have to wait for the outcome of the tribunal to implement them.

The findings of the tribunal were, to say the least, very disappointing for those people whom it was meant to reassure, namely, the victims. For them, it was almost as though they were the culprits or defendants. They were rightly offended at the lack of consideration shown to those among them who were called to give evidence. They had difficulty in accessing information and documentation. They also feel aggrieved at the failure of the tribunal to pursue issues which they felt would get to the truth, namely, the questions I have outlined. Most significantly perhaps, the tribunal failed to establish why the system failed and how 79 people died as a result of that failure. Now that the question has been raised again here, the Minister will give a reassurance that answers will be provided.

The tribunal report raises many questions to which it is very limited in providing the answers. At a minimum, this is demoralising for those families who have been affected. It is also very frustrating that so much time and money was spent with the objective of establishing a number of salient facts about the infection of people with haemophilia and the causes of the deaths of 79 people. More than this, those responsible for allowing this to continue have not been called to account for their actions in any substantial way.

Mr. Gormley

I will share my time.

It is remarkable that the Lindsay tribunal report which deals with loss of life and real human tragedy was not given the same coverage as the Flood tribunal report. In this regard, considerable credit must go to Mr. Paul Cunningham of RTE who has done a fantastic job in highlighting and analysing the issues and ensuring the victims are not forgotten. This proves, once again, how important public service broadcasting is. The Flood tribunal report was greeted with enthusiasm because of its directness, clarity and willingness to point the finger. Regrettably, the Lindsay tribunal report pulls its punches.

The Government motion states that we accept the findings of the report. While this is true, it applies only in so far as they go, as the report does not get to the heart of the matter. It fails properly to apportion blame, a failure which has left many people in the Irish Haemophilia Society bitterly disappointed.

The Lindsay tribunal took two years to sit and a further ten months to report. Contrast this with the Finlay tribunal on hepatitis C which sat for only two months and pointed the finger. The public will no longer tolerate this type of wishy-washy report which allows people to make excuses and effectively exonerates them from wrongdoing. The beef tribunal was an example of this equivocal attitude. The Irish Haemophilia Society was entitled to ask the reason a judge from the Circuit Court was appointed to such an onerous and sensitive tribunal.

Why did the tribunal fail to investigate certain matters or call crucial witnesses? Why were no board members of the BTSB called to give evidence? Why did the tribunal fail to investigate Accuscience which imported Factor 8 concentrate? This was the same company of which Mr. Sean Hanratty from the BTSB was a director. Mr. Hanratty subsequently destroyed the relevant documentation in the BTSB. All of this is scandalous. It represents a clear conflict of interest and constitutes an attempt to pervert the course of justice. Let us be very clear: people died as a consequence of this negligence. In France, in similar cases, people went to jail.

This report will not cause any of the main protagonists to lose a night's sleep. The victims, on the other hand, have lost not only many nights' sleep, but their health and their lives. The inquiry revealed the arrogance of the medical profession and gave us a glimpse of the criminal negligence of the pharmaceutical companies while not getting to the heart of it. The power of the international pharmaceutical companies is a matter I have raised here in the past. We see it reflected in their influence on Government policy and on the Irish Medicines Board. We saw evidence of it in the vaccination scandals and we see it in relation to MMR. The Lindsay tribunal report gives us a further insight into it, even if only a glimpse.

The Irish Haemophilia Society sought an investigation of the international pharmaceutical companies. After much toing and froing Ms Justice Lindsay ruled that she did not have discretion under the terms of reference of the tribunal to investigate the companies in this jurisdiction. Later the Attorney General under direction from the Minister asked for an investigation into these companies. I do not intend to go into the correspondence between Judge Lindsay and others on this issue as it has been comprehensively documented in the IHS document in the report. It is quite clear, however, that there was not just a reluctance to investigate these companies, but that there was no intention of doing so from the beginning. This was an appalling and astonishing decision given that 74 Irish citizens died as a consequence of being infected by blood products manufactured by these companies.

We need to get this information. We also need to establish who gave false information to previous Ministers for Health. This is a crucial question which I hope we, on the Committee on Health and Children, will be able to examine in detail in the future. I am committed to finding the truth. There can be no more evasion, diversion and cover ups. We must have the full truth and we must punish those people who are guilty of these crimes, because they are crimes.

Dr. Twomey

It is clear haemophiliac patients died because of decisions, some intentional, others unintentional, made by doctors and administrators. They died because of ignorance of the causes of the infection and the inability of our health care system to respond to the changes HIV inflicted on our society. Before this report can be put away, we must get closure on the role of the international pharmaceutical companies with regard to infected blood products. The first paragraph of part VI of the report, which covers recommendations, states: "the main focus of the tribunal was on the past rather than the present." It continues: "great changes have taken place in personnel, facilities and procedures since the occurrence of the events which were investigated by the tribunal".

Could it all have been prevented? The Lindsay tribunal report is a perfect example of how it can all go desperately wrong when doctors do not speak up and the Government of the day refuses to input the resources the health services need. Reading through the letters in the appendices, it becomes clear that there was an immense lack of knowledge about HIV and AIDS in the mid-1980s, even in medical circles. I entered medical school in 1987 when ignorance of the HIV issue was common among the young people with whom I socialised. It comes as no surprise that the Virus Reference Laboratory only started using HIV antibody testing kits in April 1985. There was confusion in the medical profession as to how we should deal with HIV. We oscillate between an in-your-face giving of the facts and an ostrich-like approach of burying our heads in the sand and trying to ignore it. Let us look at the approach of the Government of the day to this issue. In part V, division III, chapter 9, of the Lindsay tribunal's report, the history of the national haemophilia service co-ordinating committee is given. It was established in 1971, but by the mid-1980s at the height of this endemic its meetings were held infrequently and, as the tribunal comments, there is little doubt that its work and effectiveness were adversely affected by a lack of resources. Everybody should read this chapter as an example of how complacency and bureaucracy led health services into a catastrophe that could easily have been avoided.

That is not the only example of what was obviously a casual and non-urgent response to the growing crisis by that Government. In 1985, at the height of this crisis, there were four consultant haematologists in the Blood Transfusion Service Board and they acted as the medical experts examining blood products on its behalf. One retired in December 1985, but was not replaced, another retired in 1986 and was not replaced immediately meaning that in 1986, when this crisis was at its worst, the BTSB had only half the number of consultants it had when it started. It gets worse. One of the two remaining consultants retired in December 1987. This doctor worked in Cork and his position was not filled until a consultant was appointed in 1989, instead he was replaced on retirement by a medical registrar. There was only one consultant in Dublin for most of 1987 and 1988 until a consultant was appointed towards the end of the latter year. If this was a move to save money rather than lives, let us benefit from hindsight to stop it happening again.

I am under no illusion that the health services face similar problems today. We have more diseases, more illness, a more elderly population and a shortage of doctors across all specialties. The present structures and responsibilities of the Department of Health and Children are not going to work because they are too expensive and the Department cannot handle its diverse brief. The interface between the Department and the people is the health boards, but these old-fashioned structures are from another era and require radical reform quickly.

The structure of how health care is delivered by doctors also needs reform in general practice and, especially, in hospitals. This is not the Minister's problem alone, it is a collective problem to be faced by the Cabinet. There is no doubt that the cutbacks of the 1980s played a role in this crisis and we are facing such cutbacks again. Depriving 250,000 citizens of free health care for another year is morally wrong when millions may be wasted on a politically bloated health board structure. The Taoiseach has spoken of doubling health care spending since 1997, which is when I began to work as a GP, but I have not seen the fantastic improvement in health services that one would expect.

As a doctor and a Member of the Oireachtas, I hope that no more lives will be lost because we were slow to reform the health services. It was with great sadness that I read about the cases of these many people and I do not want to see the same thing happen again.

Mr. English

The film "Children of a Lesser God" which was made some years ago dealt with the lives of a number of physically challenged children. While the subject today is not the same, the title of the film sums up how the people directly affected by those poisonous blood products must feel. For me, or anybody else, to claim to know how these people feel is to take a great liberty, but it would not be the only liberty this country took in dealing with the victims of the incompetence which seemed to go hand and hand with the Blood Transfusion Service Board at the time of this crisis. Are these people citizens or criminals or, indeed, are they even human? I have news for us all here. They are citizens and human beings, not that it made any difference, and the only crime they committed was to need and believe in a service guaranteed to them by the State.

Unlike modern day criminals who operate in a revolving door system, these people received a life sentence for the crime of being sick and paid the price with their lives. What these people and their families endured and are enduring we can only guess, but what we, the political establishment, forced them to endure over and above what was an already unbearable cross is a national scandal and a total disgrace.

I will not go over the whole story which has been well documented by now, but I express my utter disgust at the way in which the cases of these people were handled by the State and its servants. It is with no honour that I say those responsible for this unbelievable tragedy came from both sides of the House as this tale of woe went from Minister to Minister and Government to Government and each tried to ignore, forget or bury the problem. As politicians, we must all hold up our hands and say that we are sorry. We must learn the lessons which are clearly on show for us today and vow to never again ignore the pleas of our sick and injured, no matter what the cost.

It does not appear that we have learned the lessons. The Lindsay tribunal was eventually and begrudgingly set up by the State when it finally realised that these sick people were not going away, but they were still ignored at every opportunity. The terms of reference of the tribunal, its limited powers of investigation and its final results fell far short of what victims who had suffered enough already expected from the justice system of a land of saints and scholars.

Comparing the findings of the Lindsay tribunal with those of the interim report of the Flood tribunal is like comparing chalk and cheese and the blame lies with the Minister and the Government of the day under whose administration it was established. Despite countless meetings and requests by the victims and their families, its terms of reference were cast in stone for reasons best known to the Government. That was wrong. It is said that two wrongs do not make a right which this Government and its predecessor have done their best to show.

The unforgivable mistakes and mismanagement of the BTSB are directly responsible for this crisis which befell ordinary, decent and undeserving people. When that is coupled with the mismanagement of the crisis by Governments, it adds up to two giant wrongs, one of which caused almost as much pain as the other. The air of secrecy and mistrust which grew out of this tribunal reflects no credit on anybody, but to say that this air was expected of civil servants would be close to the truth. The proof is that even today some of our health boards and hospitals have refused to release valuable information and records needed by the tribunal. All I can do here is ask why that is, who they are kidding and why they think they can do it. Even at this late hour, I ask all involved to become willing participants in the tribunal process. I ask the families and friends of the victims to keep fighting because their courage and bravery are an inspiration to us all. With their courage and our support we will hopefully see this through to the end and I ask the Government to send the tribunal back to work until it comes up with definite answers. The Minister has said that this matter is to be referred to the DPP, which I ask to be done quickly while also requesting that the Garda is involved.

It is only by a stroke of luck or the hand of God that one of us here is not the victim of something that could have happened to anyone. The truth may hurt, but it will always be our friend be we statesmen or political leaders.

Mr. Morgan

I wish to share time with Deputy Finian McGrath. I wish to reiterate the comments of my party colleague, Deputy Caoimhghín Ó Caoláin, in welcoming 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. Sinn Féin broadly supports the Government's motion and the amendments tabled by Fine Gael and the Labour Party and welcomes the Government's commitment to implement the recommendations of the report. I also welcome the decision to refer this report to the Director of Public Prosecutions.

A number of issues arise from the publication of the report on which I wish to comment. The Irish Haemophilia Society in its response to the report of the Lindsay tribunal stated it should be known that in the course of establishing and participating in the inquiry the Irish Haemophilia Society had to overcome many obstacles. The society expressed concern over the adverse adversarial attitude of the tribunal towards people with haemophilia and their families. In its criticism, the IHS referred to two incidents in particular, the comments of John Finlay, SC, counsel on behalf of the tribunal, who during the course of the evidence of Ms Linda Dowling, whose father died from the consequences of HIV and hepatitis C infections, said that the tribunal should not over-indulge the witness any longer, and his question to a witness who had contracted HIV regarding how he had spent his compensation money. The disappointment of the society over this report becomes increasingly clear when one realises the difficulties it overcame to participate in this tribunal. Particularly harrowing for the society were the difficulties it faced in its attempt to obtain priority for its witnesses, many of whom were seriously ill, in the order of witnesses to deliver evidence before the inquiry.

In light of these difficulties the victims deserved a more thorough investigation and a conclusive report. On reading Ms Justice Lindsay's report I was extremely disconcerted to find that it failed to assign responsibility for infection of haemophiliacs with HIV and hepatitis C. Why does the Lindsay report not include criticism of Armour, a company which took a decision in June 1988 to continue supplying a product to the BTSB about which it had serious safety concerns? Evidence was given to the tribunal of the knowledge of Armour Pharmaceuticals Limited of the HIV infection risks posed by Armour products which it continued to distribute in Ireland.

I wish to express concern that the tribunal failed to investigate certain matters. Why were all board members of the BTSB not called to give evidence? Why did the tribunal fail to investigate various Ministers for Health who had ultimate responsibility for policy decisions such as the non-implementation of national policy in respect of Council of Europe recommendations? Why did the tribunal fail to investigate the late Mr. Sean Hanratty, former chief technical officer of the BTSB, who had a key role in deciding what product was used and who was also a director of the company which acted as an intermediary for Myles Laboratories Incorporated, which supplied non-heat treated and unscreened so-called Cutter products which were responsible for some of the Irish infections? Mr. Hanratty was also responsible for destroying BTSB paper work that could have been used to identified precisely which products caused infection.

I would like to address a number of comments made by the Minister for Health and Children, Deputy Martin, in his contribution to the House on the report of the Lindsay tribunal on 23 October last. In relation to the possibility of the establishment of a tribunal to investigate the role of the pharmaceutical companies, will the Minister clarify precisely what he had in mind when he stated that he believed it would be possible to mount a useful investigation which would allow access to publicly available materials and to persons and bodies willing to co-operate? Sinn Féin has called for the establishment of a adjudicative tribunal to investigate the role of the pharmaceutical companies because it is our belief that any other form of inquiry or tribunal will not result in those responsible for the infection with HIV and hepatitis C of persons with haemophilia being held accountable. Is the Minister aware of the comments by Mr. John Finlay, SC, counsel for the tribunal, on 20 July 2001 that he foresaw at the very least a potential problem in investigating the role of the pharmaceutical companies as it was his understanding that documents would be only released under American Judicial Assistance Statute to an adjudicative tribunal and not an investigative one? Will the Minister inform the Dáil if he has received advice to the contrary and, if not, how the people of this State can have confidence in what he terms "useful investigation"?

Mr. F. McGrath

The Lindsay tribunal report is perhaps one of the most important issues that has come before this House. Before getting into the detail of the debate, I wish to welcome the comments by Deputy McManus this morning on the differences last week between the technical group and the Labour Party. I concur with her views. As far as I am concerned this issue is bigger than all of us and one we must take seriously and get on with addressing.

For me, this is a human story of sickness, tragedy and death. I express support and sympathy to all the families concerned. I acknowledge the extraordinary suffering endured by those with haemophilia who were infected. It was a nightmare and none of us can understand the hurt and the pain. For what it is worth, I as a newly elected Deputy and a member of the Health Alliance will do my best inside and outside the Dáil to ensure that those affected receive justice. I acknowledge their personal testimonies given to the tribunal of inquiry. We have had inquiries about corruption, planning and sleaze, but for me this is the most harrowing and must be given top priority, which I certainly intend to give it.

Paragraph 4 of the motion refers to the public dismay at the matters disclosed in the report, but for me it was more than dismay. There is massive public anger at the way these people were treated. We must act on this crime against humanity. That is why I strongly support the decision to refer the report to the Director of Public Prosecutions. There must be a response from the State based on justice and fair play. To date these people have not received fair play.

Page 21 of the report states that the tribunal sat in public for 196 days and 146 witnesses gave oral evidence to it. That speaks for itself. We saw the tragedy and the pain of this terrible crime against a group of Irish citizens. We can sit here all day debating this sad report, but the bottom line is that if the State does not act in a positive and constructive manner, we fail as politicians, democrats and, above all, as human beings. These people were poisoned. There is no point in beating around the bush. We owe it to the victims and their families to do three simple things. First, apologise and accept total responsibility, second, those who are guilty must be prosecuted and the families concerned properly compensated and, third, ensure that this type of horrific crime against a group of our people never happens again.

Mr. Connolly

Some €20 million has been spent setting up and servicing the Lindsay tribunal of inquiry into the infection of more than 200 haemophiliacs with HIV and hepatitis C through contaminated blood and blood products. In light of its recently published report, I consider the tribunal to have been an expensive exercise in futility in that a vast amount of taxpayers' money was expended in discovering precious little and scarcely apportioning blame for the debacle. Culpability and responsibility were fudged in the report to the extent that it revictimised the victims and the second injustice was almost worse than the first. The report demonstrated an appalling lack of sensitivity for the victims of this tragedy and a total lack of understanding or appreciation of what they endured. It is patently clear that the major share of the blame must attach to the Blood Transfusion Service Board. Its failure to provide HIV-free home produced product for haemophiliacs prior to 1984 was inexplicable and its failure to heat treat Factor 9 and withdraw non-heat treated Factor 9 directly led to the infection of seven haemophiliac sufferers with HIV and the subsequent death of five people.

Debate adjourned.

Sitting suspended at 1.30 p.m. and resumed at 2.30 p.m.