The taintedblood Timeline  -  what really happened...

In a letter from Wessex Regional Transfusion Centre (WRTC) to the Head of Quality Control, BPL, we learn of a male blood donor who has been admitted to "a Bournemouth hospital; the clinical diagnosis is almost certainly AIDS."

The letter outlines the previous donations of the male donor, who had donated blood in November 1982 in Leeds, and three more times at Bournemouth in September 1983, March 1984 and September 1984.

"There is also the possibility of a donation before November 1982 in this region, which we are attempting to trace." It appears that the September 1983 and March 1984 donations were already used.

Note: We cannot help but wonder why there aren't any recommendations here to alert patients?

In another WRTC letter from the Deputy Medical Director to various Consultant Haematologists in the South, including the Lord Mayor Treloar school, the author explains the reason for the recall. The Deputy Medical Director makes the following unethical request of the centre directors:

"In order to prevent undue worry to your patients, may I ask for your discretion here and, for the time being at least, to keep this news to yourself."

Note: We are perturbed to read that Doctors are specifically told not to tell patients, thereby putting partners/spouses at risk.

In handwritten briefing notes entitled 'AIDS Contamination of Factor VIII Concentrate' from DHSS HS1 division, we learn that there were substantially more vials of contaminated Factor VIII made from the suspect donation of March 1984.

In fact, a total of 885 units were supplied as follows:

• 485 vials were sent to Wessex RBTS on 10th August 1984

• 400 vials were supplied to Cardiff RBTS on 17th August 1984

The notes go on to say that: "They were passed down to Haemophilia Centres for supply to patients. Thus it is known by the Centres precisely which patients received supplies from this batch. BPL are recalling the batch and this is under control."

Note: It is interesting to observe that the title of these briefing notes makes use of the term 'AIDS' when the diagnosis of the donor wasn't officially confirmed until eleven days later (on 16th October 1984).

In a letter from the Wessex Regional Transfusion Centre (WRTC) to BPL, the details of a contaminated Factor VIII batch HL3186 are discussed along with how many vials were unreturned. Of the 485 that had been sent out, only 95 were returned.

• This clearly leaves 390 contaminated vials unaccounted for.

Note: We are extremely concerned to read that 167 vials of this contaminated batch were used up at the Lord Mayor Treloar College, Alton - a well-known specialist school, catering for boys with haemophilia. Only 33 vials out of a total of 200 were returned from the Treloar school.

Note: We believe that there was a good chance that the WRTC were aware that most, if not all, of the 390 unreturned vials had already been transfused into patients. Presumably these patients could have been easily traced and informed?

In a letter of 16 October 1984, from WRTC to all Haemophilia Centre Directors in Wessex, we find confirmation that: "the diagnosis of AIDS has now been confirmed." The Deputy Medical Director goes on to say that further contact will be made: "within the next day or so" regarding follow-up of patients, but that: "in the meantime I have been asked to suggest a policy of discrete surveillance be pursued."

Note: It is disgusting to read that despite the donor having a confirmed AIDS diagnosis, the official line of the Deputy Medical Director and the WRTC is still not to inform patients.

Then in a letter from WRTC dated the same day, a Consultant Pathologist is notified at the Royal Naval Hospital, Gosport, Hants. This correspondence is obviously the first the RN Hospital has heard of the contaminated batch - and for some reason 12 days later than anyone else.

In a third letter of 16th October 1984, the WRTC write to the Queen Alexander Hospital, Portsmouth, where we learn of another hospital where this notification is the first they've been told about receiving the contaminated batch.

Note: As with the Naval hospital, why weren't these hospitals informed earlier?

A letter from the Public Health Laboratory Service (PHLS) in Manchester, details the discovery of a batch of Factor VIII [Batch No. HL3186] that was made from pooled plasma where one of the donors was later confirmed to have antibodies to HTLV-3 (HIV). The letter also confirms that epidemiological follow-up studies are to be carried out on the recipients of that batch.

• We know that Dr Craske had detailed knowledge about the situation regarding AIDS in the USA, especially since he was tasked with looking into reports of the syndrome in 3 haemophiliacs from the United States in September 1982.

• Dr Craske even knew about the connection between AIDS and US commercial blood products.

• We also know that from October 1983, the UK Haemophilia Centre Directors had considerable, documented awareness of the risk of AIDS to the spouses of haemophiliac patients.

With this in mind, we strongly believe that the physicians involved in this BPL product recall were remarkably casual in their approach to dealing with it. The delays incurred in telling patients meant that their wives and partners were put at risk. We would suggest that this was because of directives from Dr Craske.