Com. of Inquiry opens hearings on tainted blood
The three man commission of inquiry appointed to investigate the circumstances under which three patients at the K.H.M.H. received HIV infected blood, convened this morning in Belize City. Although cameras were barred from the public proceeding, News 5’s Ann-Marie Williams was in attendance and she joins me in the studio tonight for an update.
Ernesto Vasquez
?Ann I understand that you were at the inquiry for the blow by blow proceedings. First, give us some background and tell us who were involved in this inquiry.?
Ann-Marie Williams
?The Commission of Inquiry is appointed by the Prime Minister and it literally has three men on it. The Chairman is former Chief Justice Sir George Brown, Ombudsman Paul Rodriguez, and Dr. Leroy Taegar. The Commission started this morning 10:10. The chairman laid down the rules of the commission, why they?re there, saying particularly that the terms of reference of the commission is set up to investigate the circumstances surrounding and leading to the transfer of HIV positive blood to three people, during the period March twenty-eighth to April tenth at the Karl Heusner Memorial Hospital. He said that seven people over maybe a two-week period may be called to testify. The first witness this morning was the director of the Central Medical Laboratory, Mrs. Trudy Tillett. She was administered her oath by Beatrice Gill, she is the secretary at the hearing, recording all proceedings. She actually started out by taking her oath as I said, then she sat down and the chairman asked her to outline what she does at the laboratory.?
Ernesto Vasquez
?Being that this is the first day, what came out of it??
Ann-Marie Williams
“She basically when through the procedures, who she is in charge of, how everything is worked step by step. The interesting part had to be when she describes how the blood was actually taken. You go up to the third floor of the lab, get the blood taken, samples are sent down to serology, she?s in charge of that section and then…?
Ernesto Vasquez
“Where is this lab? At the hospital??
Ann-Marie Williams
“It?s between the Social Security building and the K.H.M.H.?
Ernesto Vasquez
“That?s the Central Medical Laboratory, it?s called??
Ann-Marie Williams
“Yes. So the blood, if it?s not finished testing, all the processes, it goes to the Stat Lab, but it?s tagged prior to going to the Stat Lab at the K.H.M.H. So the blood actually went over there and it was in case of an emergency, and it was fresh blood, which they needed that particular day. Somebody had to verify if it was already tested.?
Ernesto Vasquez
“So the blood wasn?t completely tested at the Central Laboratory??
Ann-Marie Williams
“Right, and somebody went on and used it. And that is what the Commission of Inquiry is hoping to find out at the end of the two week period, who are the people liable and what is exactly will happen. So she went through all the different processes, set backs, lack of man power, lack of trained people, all the different things she could have said about the lab, she went through blow by blow. She also said that she was on sick leave from the fourth of April to the tenth.?
Ernesto Vasquez
“So she wasn?t actually when the…?
Ann-Marie Williams
“She was there when there within a certain period of time, but since nobody can substantiate fully or haven?t been able to substantiate at least when it started, she was on sick leave from the fourth to the ninth. When she came back on the tenth, she was told by the senior technician, Mrs. Ebanks, that this is what happened. She said she immediately convened a meeting with Valerie Jenkins, Dr. Sosa, Dr. Arriaga, some other senior people, and they made, at least a plan, saying that blood will not go over there unless it?s fully tested, at least for an interim period, and no more than three units of blood will go over on any given day. And they?re hoping to put that measure in place until something substantial can come out.?
Ernesto Vasquez
“That is as a result of what has occurred. But right now the big question is this blood was taken over to the K.H.M.H., was not completely tested, but it is tagged that it?s not completely tested. Someone took it and used it even with the tag, so this is what they?re trying to find out.?
Ann-Marie Williams
“Yes. So they?re trying to interview seven people over the next two weeks to exactly say what happened. This afternoon after Mrs. Tillett finished her testimony, the supervisor of the Blood Bank, Joy Charlie, who has been in the lab system for twenty-nine years and sixteen with the Blood Bank, she started her testimony. She was just briefly explaining what she does at the Blood Bank, and tomorrow they will convene with exactly she and the phlebotomist. But during the proceedings today, what I found particularly interesting was when Paul Rodriguez asked Mrs. Tillett ?why take the blood over to the Stat Lab if it?s not properly tested?? and she said ?well in case of an emergency.? And he said, ?but in an emergency you won?t be able to use it anyway because it?s not tested. And the chairman, Sir George Brown, actually had a problem trying to find out why would this blood be tagged red, it?s not to be used and somebody would actually go about and use it. I spoke to him earlier this afternoon.?
Ernesto Vasquez
“I think we have a clip of that.?
Ann-Marie Williams
“Yes we do.?
Sir George Brown, Chairperson, Commission of Inquiry
“Units of blood would leave the Blood Bank and be taken over to what they call the Stat Lab in the hospital, before it was screened and clean. In other words, they said it was safe blood. We learnt that it was only over the last two years or so that this sort of this developed and they have discontinued it.”
Ann-Marie Williams
“At the end of the day when all the witnesses have been called, what is it that you hope will come out of the Commission of Inquiry?”
Sir George Brown
“Well in the end we have been called upon to look at what actually happened, find out what happened, whether it was human negligence, whether there was inadequate machinery in the system and make recommendations as to how the system could be improved. So this is what we are all about.”
Ann-Marie Williams
“And what will happen to those people…To the people who are blameworthy.””
Sir George Brown
“Certainly, if we find any negligence, we will be recommending what ought to be done to the person or persons who are negligent.”
Ann-Marie Williams
“Can you elaborate on some of the other witnesses that will be called in terms of their names or their positions?”
Sir George Brown
“We’ve started with Mrs. Charlie, who is a supervisor, and she is next in line in the hierarchy in the Central Medical Lab. She is the supervisor of the Blood Donor Service, that whole section, the Blood Bank and up to the point in time of this incident, of the Stat Lab, which is located in other building in the hospital itself. Since this incident, that has been discontinued. Someone else has been placed in charge as a supervisor, who can be monitoring on a twenty-four hour basis, because that is where emergency blood is requested and supplied for.”
“Commissions have been set up since, as I’ve said 1989, there’ve been ’91, there’re about six up to this point in time, in 1999, ’98, going backwards. They are not used that often, but in fact it is a form of introspection, where government looks at itself, sets up a body to examine what has happened or what went wrong in a department, what went wrong in the operations of departments or institutions for which it is responsible, and the way in which officers have performed their duties. Let’s look at it this way, a government is what we call vicariously liable for the actions of its servants.”
Ernesto Vasquez
“Ann what?s the next step now? What happens after this??
Ann-Marie Williams
“The Commission of Inquiry resumes tomorrow morning at 10:00 sharp and Joy Charlie, who is the supervisor of the Blood Bank as I said before, she will continue her testimony. And also Marjorie Mariano, who is the phlebotomist at the Blood Bank, she will testify in the afternoon. The proceedings last from 10:00 until 12:00 and 2:00 until 4:00.?
Ernesto Vasquez
“Ann, thank you very much.?
Two of the patients who received the infected blood have died due to unrelated causes, while the third is said to be receiving treatment in the form of anti-retroviral drugs, courtesy of the Ministry of Health.