Test results sent to Dublin in 1991 by the Middlesex Hospital in London showed that blood products provided to patients by the the Irish Blood Transfusion Service Board (BTSB) were contaminated with hepatitis C.
But the report, handed by the Irish cabinet this week to the Director of Public Prosecutions, found the BTSB's response to the London findings "completely inadequate and non-existent". It was also scathing about the BTSB's decision to not to recall contaminated products until February 1994.
Recent figures show that 970 mothers with with rhesus positive babies receiving anti-D blood plasma treatment and 210 haemophiliacs were infected with hepatitis C from contaminated BTSB supplies.
The report, by Mr Justice Thomas Finlay, placed most of the responsibility for the failures in 1976-77 and between 1991 and 1994 on senior BTSB staff, including the founding director, Dr James O'Riordan, now 83, senior biochemist Cecily Cunningham, and Dr Terry Walsh, a chief medical consultant with the BTSB who in 1976 was a junior doctor in charge of donors.
Strong criticisms were also made of Dr James Kirrane, who in 1977 failed to seek an investigation after being told by Dublin's Mater Hospital of reactions among those who had received the anti-D product.
In a damning passage Mr Justice Finlay condemned what he called the BTSB's "total refusal to face the consequences of what had been done" in 1976.
The inquiry followed the High Court action of Brigid McCole, who died last October days before her case was due to begin. She was determined to establish publicly how she and hundreds of others had been infected since the mid-Seventies. Shortly before her death last October she accepted a settlement of pounds 175,000.
Following claims of ministerial negligence, Brendan Howlin, health minister from 1992 to 1994, said yesterday that trying to blame the minister was "like trying to blame the fire brigade for the fire". But he said "the government as a whole will have to take its share of the responsibility". Compensation payments are expected to exceed pounds 100m.Reuse content