It’s a submission by legal firm Turner Freeman on behalf of some of those Australians. If you want to understand why people like “tainted blood” campaigner Charles MacKenzie and Medical Error Action Group founder Lorraine Long are still fighting for the Australian government to act on the Senate inquiry’s very limited recommendations, you need only look at the Turner Freeman submission.

If you want to know why “tainted blood” victims – those who are still alive – and their families are still outraged and despairing of government responses to this most tragic of human health disasters, you need only read how foreseeable the disaster was.

And if politicians of all persuasions want to know why Australians voted the way they did on July 2 – with a reasonable percentage of people giving the finger to the major parties – they need only look at how governments across this country responded when a foreseeable health system failure had a catastrophic impact on thousands of people.

Or didn’t respond, as is the case here.

It’s just one example of an institutional failure having a catastrophic impact on individuals, where those most responsible try to avoid responsibility, individuals are left fighting institutions, and governments do as little as possible.     

The Turner Freeman submission documents what the Australian Red Cross knew about certain blood donors in the 1980s, whose blood donations went on to infect people with hepatitis C.

There was donor B, whose Red Cross record included a notation in 1983 that he or she was “not to donate until April 1988”, because of known risk factors.

The Red Cross record showed blood was taken from donor B on at least two subsequent occasions.

“The blood collected on the second occasion was subsequently transfused to one of our clients and infected him,” Turner Freeman told the Senate inquiry.

Then there was donor C, an IV heroin user sharing a needle in 1982, who had had “approximately 70 sexual partners”; or donor E, whose record in 1984 noted “Do not call until August 1989”, also presumably because of risk factors known to the Red Cross.

Despite the note the Red Cross took blood from donor E in 1985. It was transfused to a patient in a NSW hospital who became infected with hepatitis C.

I’ve spoken with one of those infected patients who received a blood transfusion because he had a life-threatening condition. Although the Red Cross record showed the service knew a potentially contaminated blood donation had been taken and transfused into a patient, it made no attempt to contact him. He discovered he had hepatitis C a number of years later.    

The 2004 Senate report provides reasons why the federal and most state governments did not insist that blood providers use available screening methods for hepatitis C until 1990.

Before 1990 the tests were surrogates, rather than specific to hepatitis C, and because of that a small percentage of uncontaminated blood donations would have given false negatives and been discarded. This appeared to be one of the most significant reasons for waiting four years until a more specific test was available.

Another issue was the shortage of blood donations and donors. It was the 1980s when public hysteria about AIDS was at its highest and blood donors dropped from the system out of fear.    

In the four years from 1986 until 1990 the public wasn’t advised, and individual patients weren’t aware, that it was possible for blood to be screened for hepatitis C, at least in a risk-reduction sense, but that wasn’t done.

Think about that. Consider what that would feel like if you were someone who contracted hepatitis C in that four years, or a member of your family.

The Senate inquiry heard evidence from women who became infected with hepatitis C after 1990 because of blood transfusions following childbirth. A newborn baby was infected in December 1990 after a blood transfusion. It saved his life, but left him with a condition where up to 20 per cent of sufferers go on to have liver failure, cirrhosis of the liver or liver cancer.

In another case a woman who received a blood transfusion following childbirth in July, 1992, was advised seven years later that she had received contaminated blood. Subsequent tests showed she was infected with hepatitis C, which explained debilitating symptoms after her child’s birth.

The Red Cross gave her the news via a letter that started “You may remember that in 1992 you received a blood transfusion. One of the donors may have been infected with hepatitis C”.

The 2004 Senate inquiry did not favour a compensation scheme for “tainted blood” victims, but recommended a national apology, a financial assistance fund and a case-managed response.

By that stage the Canadian Government had approved a $A1.4 billion compensation fund for its “tainted blood” victims, Ireland also had a compensation scheme, and by March this year Scotland had set up a compensation scheme and English Prime Minister David Cameron had delivered a formal national apology.

In Australia?

No apology, no formal public responsibility and no action from a succession of governments who figure we have no memory.