Tribunal chairperson Ms Justice Alison Lindsay said she was satisfied the BTSB was the source of the infection for HIV in seven haemophiliacs through the issuing of two non-heat treated batches of a blood-clotting agent known as Factor IX in 1985.
Five of those have since died, while one man also infected his partner with the virus.
Ms Justice Lindsay said most, though not all those who contracted HIV would not have been infected had the BTSB withdrawn its own unheated Factor IX by August 1985. The report noted that it was "clearly inappropriate" that the BTSB had continued to issue the product seven months after similar Factor IX had been discontinued by similar authorities in Britain.
However, Ms Justice Lindsay did not believe the BTSB’s failure to withdraw the product by August 1985 was caused or motivated by well-known financial difficulties being experienced by the BTSB at the time. Ms Justice Lindsay said it was also impossible to say definitively that a Kilkenny-based patient, called Mary Murphy, would not have been infected had the BTSB introduced HIV testing before July 1985.
But she said the failure of the BTSB to introduce an appropriate look-back procedure meant Mary Murphy's infection was not discovered until 1996.
"This was completely unacceptable since she was left at risk of unknowingly being the cause of onward infection," said Ms Justice Lindsay. She had "no doubt" that the BTSB should have introduced the procedure by 1987 at the latest, instead of the actual implementation date of September 1989.
Even then, the BTSB failed to conduct a look-back of donors who had tested positive in the past in a decision described by the Tribunal as "clearly wrong." The report said it appeared the reason for this policy was a fear of "the possibility of increased litigation.
However, the Tribunal exonerated the BTSB for continuing to import and distribute commercial blood products that could have contained HIV-infection in the mid-1980s because of the prevailing medical knowledge and practice at the time. However, two BTSB officials, Dr Vincent Barry and Ted Keyes, were criticised for their failure over three months to inform the BTSB board that haemophiliacs were being infected with HIV by the BTSB's own products.
Last night, the Irish Blood Transfusion Service (formerly the BTSB) said it accepted the findings of the Lindsay Tribunal and described its report as "fair and accurate."
“While the report cannot turn back time, it is the wish of the IBTS that its conclusions and recommendations may in some way go towards alleviating the hurt and trauma caused to persons with haemophilia and their families," said an IBTS spokesperson.
Other criticisms of the BTSB contained in the Lindsay report include:
* Its failure to inform doctors of the risk of Hepatitis C from commercial blood products.
* Its failure for so long to obtain home treatment packs which would allow commercial Factor IX to be replaced by BTSB's own product.
* The failure of the BTSB to communicate the risk of AIDS to doctors in the mid-1980s.
* Delays by the BTSB in only purchasing heat-treated blood products in the mid-1980s.
* The BTSB's lack of urgency in pursuing self-sufficiency of Factor VIII.
* Its failure to issue an explicit notice to only use heat treated Factor VIII and Factor IX in January 1986, instead of six months later.
* The completely inadequate number of consultant haematologists employed by the BTSB.
* Its failure to update information on the risk of HIV infection in the mid-1980s.