Matters may "not be entirely satisfactory" in relation to demarcation of responsibility and the passage of information between the National Haemophilia Treatment Centre in Dublin and regional centres and local hospitals, according to the tribunal report.
However, it says that in more recent times the difficulties have "become less".
Dealing with events in the 1980s in the Cork regional centre, operating from Cork University Hospital, the tribunal says it is satisfied that following a meeting with Prof Ian Temperley, the consultant haematologist in charge of the Cork unit since 1979, Dr Paule Cotter, moved "with expedition" to secure supplies of heat-treated commercial products for her patients who had Haemophilia A.
But the situation in regard to her Haemophilia B patients was more complex.
"As the summer and autumn of 1985 arrived and her Haemophilia B patients were still being treated with non-heated product, she should have looked to see what other alternative products were available and at least considered whether they could have been more safely given to her patients."
The tribunal accepted, however, that account must be taken of the fact that Dr Cotter had clinical responsibility for a great number of patients and that people with haemophilia probably only accounted for 10 per cent of her time.
Moreover, it was very doubtful, even if she had taken the actions indicated by the tribunal, that the infection of her patient, named "Andrew", would have been prevented.
In relation to Galway Regional Centre, operated in Galway University Hospital, the tribunal said Dr Ernest Egan had used cryoprecipitate, a non-heat treated BTSB product, to treat patients.
The tribunal took the view this product was likely to have infected a patient of Dr Egan's prior to autumn 1985.
The tribunal believed, because of the unacceptable and unfortunate level of communication between the Galway centre and the national treatment centre, Dr Egan was unaware of the increasing disquiet about the use of unheated products.
The tribunal was satisfied that once Dr Egan became aware of the infection of "Fionn", he moved quickly to get safer products from the BTSB.
