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The Findings of the Allars Inquiry

Many of the human pituitary glands (from which the hormones were derived), were removed illegally from cadavers.

The exclusion criteria ( a crude safety mechanism requiring that certain "unsafe" glands be excluded from the collection and production process to minimise the transmission of disease to recipients) were not distributed to those collecting the glands, largely untrained and unskilled mortuary attendants. Most mortuary attendants and pathologists contacted by the Inquiry were not even aware that exclusion criteria existed.

In 1971 the exclusion criteria were amended. Glands from persons with "neurological diseases of the central nervous system due, or possibly due, to viral infection" were not to be collected after the Department's Human Pituitary Advisory Committee (the 'HPAC') was warned of the potential of contamination of the product with slow viruses. At that time CJD was thought to be a slow virus. HPAC took no steps to ensure that the amended criteria were made known to all pathologists and mortuary attendants collecting the glands. There was no response by the Department's Fractionation Subcommittee (the 'FSC', responsible for supervising matters relevant to production) to the possibility of unconventional slow viral infection of glands and therefore the final product.

The 1971 amendment to the exclusion criteria was omitted, without explanation, in 1977 when the exclusion criteria were further amended ( at that time there was considerable evidence supporting the possible slow viral contamination of the products).

Amendments to the exclusion criteria were:

"... drafted in a reactive fashion ... there was no proactive mechanism for ensuring that new sources of disease came to light. With the exception of [ an occasion in 1971, the HPAC] ...took no steps to ensure that it was abreast of current scientific knowledge of disease potentially affecting human pituitaries".

[emphasis supplied]

The amendment of the exclusion criteria in 1982, which incorporated a reference to excluding glands from persons specifically with presenile dementia ( CJD)

"was an unacceptably belated response to a series of papers [which were published in 1974 and 1977]."

[emphasis supplied]

HPAC failed to ensure compliance with the exclusion criteria.

Members of the Department's HPAC and its Subcommittees, did not have the necessary expertise in the fields of virology and neuropathology and, with the exception of one occasion, failed to seek expert advice when required.

In many instances the administration of the hormones was experimental.

The informed consent of patients was often not obtained with recipients being largely unaware that the hormones were a human biological product derived from pituitary glands removed at post-mortem.

It was found that this was a matter associated with risk and should have been disclosed to recipients. The risk of infection from treatment with a product derived from cadavers at post-mortem was a material risk in view of the known transmissible diseases, such as hepatitis, and ought to have been disclosed.

In the case of recipients of CSL's infertility hormone human pituitary gonadotrophin (hPG) , many of the side effects, some of which were life threatening, were not disclosed to recipients at all or they were not told of potential seriousness of the side effects. Recipients were not advised of a relatively safer alternative to hPG, human menopausal gonadotrophin (hMG) derived form the urine of menopausal women..

The hormones, prior to their listing as pharmaceutical benefits, were not subjected to the existing regulatory structure as required, which was established by the Commonwealth after the Thalidomide disaster to ensure that therapeutic goods for use in humans were safe and efficacious.

CSL's pituitary hormone products were dealt with in a manner inconsistent with the normal course of listing and testing of a pharmaceutical benefit.

The then Director-General of Health and the Pharmaceutical Benefits Advisory Committee (PBAC) proceeded to have the hormones listed as pharmaceutical benefits without the necessary tests being performed on the hormones by the National Biological Standards Laboratory, a Departmental Laboratory, to determine that they were safe and efficacious for use in humans.

The then Director-General of Health failed to insist on written advice from NBSL prior to recommending to the Minister that the products be listed, about the possible viral contamination of the products after a NBSL officer warned in 1965 that

- there was no safe way of limiting the collection of glands to safe cadavers and

- large viral particles, including serum hepatitis, would proceed the hormone through the column, thereby contaminating it.

It was noted by the Allars Inquiry:

"... the history of the listing of the hormones is one of circumvention of the PBAC and direct dealings between HPAC and the Director-General of Health and the Minister..."

The Inquiry also found that the Government decision-makers who established the scheme of regulation by experts committees must also take responsibility for placing the medical practitioners and scientists (members of HPAC and its Subcommittees) in a position where they had such a responsibility, and where the normal mechanism for testing and review by NBSL and other Departmental bodies, in the light of scientific knowledge, had been circumvented.

Members of the Department's Committee and Subcommittees failed to recognise the limits of their expertise.

The expertise of those members in the particular fields in which they practiced disqualified them from serving in the role of regulator.

The Minister, on the advice of the Director-General of Health:

" .... placed in the hands of those who ought to have been the regulation the very power of regulation itself".

HPAC failed in its regulatory role (this failure was also highlighted by the Committee in it's Report).

The Minister's decision to list the hormones as pharmaceutical benefits under s.100 National Health Act 1953 was an abuse of power and legally invalid (the Committee also highlighted this aspect of the AHPHP in it's Report).

The Department's HPAC, which oversaw the administration of the AHPHP, was belated in their response to the growing evidence of the transmission of CJD.

Research allocations of hormones for research projects involving some recipients were an abuse of power.

Some batches of CSL's hormones were contaminated with hepatitis and pyrogens.

HPAC failed to regulate the use of hGH and hPG outside of the official AHPHP in terms of the non-CSL hormone products produced in Melbourne and administered to patients.

During the AHPHP there were instances of the hormones being administered to recipients in research projects which fell outside of the guidelines for treatment developed by the Department's Subcommittee. The HPAC did not seek research protocols for these projects and failed to ensure that the consent of the subjects of the research was obtained pursuant to the National Health and Medical Research Council's (NHMRC) Statement on Human Experimentation (the Committee shared these concerns on the ethical aspects of the AHPHP).

The Order in Council made in 1969 authorising the use of the hormones for research purposes was in excess of power and the research allocations of hormone were unlawful.

Some decisions of two of the Department's Subcommittees, the Human Growth Hormone Subcommittee (HGHSC) and the Follicle Stimulating Hormone Subcommittee (FSHSC) were open to criticism on ethical grounds. For example:

- The HGHSC failed to appreciate that a particular scheme whereby recipients in different states were unknowingly part of comparative study, stepped across the line between making clinical observations and conducting a research study.

- The FSHSC failed to pay sufficient regard to the ethical considerations which arose from its approval to use out of date hPG in recipients despite concern being raised by CSL.

- The FSHSC failed to apply adequate sanctions in cases where medical practitioners treated recipients without the necessary approval.

- The FSHSC failed to treat hyperstimulation, a potentially fatal condition, as a central concern of the committee.

- The FSHSC failed to respond in a decisive manner to cases of multiple births and congenital abnormalities

- The FSHSC failed to consider cases of maternal deaths after hPG treatment when details became available.

These unfortunate aspects of the AHPHP were also highlighted by the Committee.

In a submission to the recent Inquiry of the Committee, Associate Professor Allars stated that she believed that the litigation would be settled after the Report of her Inquiry became available.

Despite the damning findings of the Allars Inquiry and Allars' own belief, the litigation in which we are involved has not settled. The Commonwealth and CSL have, to date, refused to compensate recipients, including our clients, for the psychiatric injury which they have suffered as a result of the negligence of others.

In its Report, the Committee highlighted the significant impact learning of the risk of CJD has had on many recipients.

The Committee recommended, inter alia, that the Commonwealth make a one-off payment to recipients who have suffered psychiatric injury. The Committee also recommended that the Commonwealth consider extending this offer to include recipients who have suffered psychological stress or a significant life disturbance. The Committee further recommended that both official and unofficial recipients be eligible for such compensation. At this stage, the Commonwealth has drawn a distinction between those who were treated unofficially and those who were treated officially. We act for a number of unofficial recipients who are also constituents of your electorate. They are deemed to be unofficial as a result of a failure of their treating practitioner to obtain the required approval prior to commencing treatment.

The Committee also called upon the Commonwealth to formally acknowledge the deficiencies in the operation and oversight of the AHPHP, the experimental nature of aspects of the treatment under the program and the anxiety and stress that has been caused to recipients.

Significantly, the Committee also recommended that an epidemiological study be conducted to determine whether recipients have suffered long term side effects (quite apart from CJD) as a result of the treatment they received. For example, in the case of female recipients of hPG, the Committee recommended that investigations s be commenced to determine whether there is a higher incidence of certain cancers such as ovarian and breast cancer in this recipient population..

In addition to these recommendations the Committee made a number of important findings as outlined below.

The Findings of the Committee

The attempts made by the Department to trace hormone recipients and advise them of the fatal complications associated with the hormone treatment and the risk that they may develop CJD were "totally inadequate". The continued reliance on medical practitioners to trace recipients, when such poor results were obtained, were not justified (many recipients were not traced and advised of the risk for some seven years after the AHPHP was suspended). The Committee agreed that for recipients who learnt of the risk through the media or at the Blood Bank, it was a totally horrifying experiences (a number of our clients and your constituents were advised of the risks in such a manner). The Committee noted:

" The Department's attitude displays a want of compassion and care for a group of people who were receiving news which would impact on them for the rest of their lives ... while there remains a group of untraced recipients, there will be doubts as to whether the Department has taken adequate steps to protect public safety by informing recipients of the risk of CJD and not to donate blood or organs".

[emphasis supplied]

As there were delays in informing recipients of the risks of CJD and that they could not make blood or organ donations, some recipients may have inadvertently made donations.

In this respect the Committee found:

" ... the Department failed to act promptly to minimise the possibility of a person treated with human pituitary-derived hormone from donating blood and organs and thereby called into question its commitment to maintaining the highest levels of public safety in Australia".

[emphasis supplied]

The Department also failed to inform recipients that their names had been supplied to Blood Banks and organ donation agencies

The Committee also noted that the:

"... Department's response to the information needs of recipients were totally inadequate prior to the Allars Inquiry investigation. Little attempt appears to have been made to prepare concise, consistent and accurate information about CJD".

[emphasis supplied]

In addition, the Committee found that it appeared that some recipients are still experiencing difficulties with accessing information held by the Department.

The Department's efforts in identifying and tracing unapproved recipients has been inadequate. The Committee considered that the evidence from the Department in relation to this issue was:

"unacceptable and a further example of the Department's lack of effort in relation to unapproved recipients"

[emphasis supplied]

The Committee had a number of reservations about the Government's response in implementing some of the recommendations of the Allars Inquiry.

In two respects it was found that the Department has relied upon an overly restrictive interpretation of a secrecy provision contained in s.135A National Health Act 1963

"to delay and/or prevent documents being made available [to the legal representatives of recipients and to recipients themselves]".

[emphasis supplied]

The Committee was of the opinion that:

"Departmental actions in this regard may have been deliberately obstructionist".

The Committee was

"... concerned that relevant documents appear to have been provided with material unnecessarily expunged or withheld totally from the legal advisers acting for the recipients".

In this sense, the Committee was referring to relevant documents of the Allars Inquiry which were discovered to this firm during the litigation. These documents contain the identity and evidence of various former Departmental and CSL's officers which is favourable to the cases of the recipient-Plaintiffs and which, obviously, harms the defence of the Commonwealth and CSL.

A sixth month delay on the part of the Department in the provision of relevant Allars documents to this firm during discovery

"could be regarded as deliberately obstructionist".

[emphasis supplied]

"a range of possibly relevant Departmental and CSL files have been destroyed"

It was noted that

[emphasis supplied]

The destruction of these files was apparently in accordance with standard Australian Archives Procedures. The Committee noted that according to these procedures destruction of the documents could only take place with the consent of the Department.

The Committee considered that

"the action of the Department (as the Defendant) in advising AGS in the release or refusal of documents to the plaintiff and yet having full access to the same records in instructing AGS on their defence is at least inappropriate, if not unethical".

[emphasis supplied]

The Committee commented on the Department's evidence before the Senate Committee, where it attempted to divert responsibility away from the Department for HPAC's failure to ensure that the exclusion criteria were made known to those collecting glands and to ensure compliance:

" The Committee considers that the Department's statements ... raises serious concerns about its understanding of the ethical matters and accountability issues raised by gland collection and the monitoring of exclusion criteria as detailed in the Allars Report"

[emphasis supplied]

Following the enactment of uniform tissue legislation, the Committee noted:

" ... the Health Department failed to act to ensure that glands for the AHPHP were collected in a lawful manner. Not only did the Department have a role in overseeing the AHPHP, but it also had representatives on HPAC and should have ensured that legislation was complied with".

[emphasis supplied]

Some of the members of the Department's Subcommittees did not know that there were restrictions on the collection of glands.

The Committee considered:

" ... that the Allars Inquiry raises serious concerns about the role of government agencies in the establishment, control and accountability of the AHPHP .... the Department's comments about the decision making process in relation to the AHPHP and the matters addressed by the Allars Inquiry concerning the role of government agencies and accountability issues raise doubts as to whether the Department understands its responsibilities in this area".

[emphasis supplied]

The Committee noted the finding of the Allars Inquiry that the power to regulate was entrusted to those who ought to have been regulated and commented that it appeared that this arrangement was never challenged.

In relation to the criticism that was levelled at the Department during the Committee's public hearings, the Committee considered that:

" ... it is no excuse for the Department to say that 'the decisions taken regarding the establishment and administration of the AHPHP were taken up to three decades ago and were based on the standards of the day. In fact this statement is erroneous".

[emphasis supplied]

In relation to the Department's response to the recent sixth case of CJD in the Australian recipient community, the Committee was:

"... concerned that it appears that the Department has again failed to respond adequately to a situation which has far reaching implications not only for one particular recipient and her family but also the whole recipient community"

[emphasis supplied]

The Department was also criticised for failing to advise recipients of the sixth case prior to the media disseminating the information. The Department's approach was considered to be "passive and overly officious".

The Department failed to respond to developments between 1985 and 1988 which raised "serious concerns" about the decision-making processes in the Department.

The Report concluded:

" ... the Committee is concerned that incorrect or incomplete information was provided to the Allars Inquiry concerning possible contamination of batches of hormone and whether or not they were distributed for recipient treatment. The Committee considers that this had added to the distress of some recipients and should not have occurred".

[emphasis supplied]

Karen Weeks


3 November, 1997


Macedone Christie Willis -

Letter to Federal Parliamentarians

KW:951015 3 November, 1997

Dear Sir/Madam,


As you are aware, we act for a number of recipients of human pituitary hormones who have commenced legal proceedings against the Commonwealth of Australia (the 'Commonwealth'), the Commonwealth Serum Laboratory Ltd ( the 'CSL') and various medical practitioners.

A number of our clients are constituents of your electorate. Our clients, in addition to over 2000 other human pituitary hormone recipients Australia-wide, are at risk of developing a fatal degenerative neurological disease, Creutzfeldt-Jakob Disease (CJD) as a result of the hormone treatment they received. The human pituitary hormones were manufactured by the CSL Commission from 1966 until 1985 and were distributed under a program administered by the then Commonwealth Department of Health, now the Commonwealth Department of Health and Family Services ( the 'Department'). The Australian Human Pituitary Hormone Program (the 'AHPHP") was suspended in 1985 following reports of the deaths of recipients overseas from CJD. Most recipients were not advised of the fatal complications associated with the hormone treatment and their significantly increased risk of developing CJD until some seven years later.

It is known that five recipients in Australia have died from CJD in recent years as a result of receiving injections of CSL's hormones which were contaminated with the infective agent of CJD. A sixth recipient has recently developed symptoms of the disease almost thirty years after the treatment was administered and is expected to die shortly.

The recent Report of the Senate Community Affairs References Committee (the 'Committee') again drew the public's attention to this most horrific chapter in Australian medical practice. Prompted by concerns that a recent offer of settlement made by the Commonwealth was not fair or adequate, the Committee considered a number of issues relevant to the Department's and CSL's role in the AHPHP. These issues included the actions of the Department in the conduct of the litigation and whether the safety of the public was adequately protected by inter alia the CSL, the Department and/or other Commonwealth departments and agencies.

The Report of the Committee is the second damming Report of the Department's role in the AHPHP which has emerged in recent years and has revealed again for general public scrutiny the mismanagement, major flaws and ineptitude which dominated the program.

In 1993 the then Minister of Health, Senator Graham Richardson announced an Independent Inquiry, the Inquiry into the use of Pituitary Derived Hormones in Australia and Creutzfeldt-Jakob Disease chaired by Associate-Professor Margaret Allars (the 'Allars Inquiry'), after deaths of a number of Australian recipients emerged. In 1994, the Report of this Inquiry (the 'Allars Inquiry'), was tabled in Federal Parliament. Like the Committee's recent Inquiry, the Allars Inquiry made a number of damning findings.

We are currently awaiting a formal response from the Commonwealth Minister of Health and Family Services to the recommendations made by the Committee. It is hoped that the Minister will implement the recommendations contained in the Committee's Report and compensate our clients and other recipients who satisfy certain criteria.

If the recommendations are not implemented, those recipients who continue with the litigation to seek compensation for their injuries would be placed in the unenviable position of having to attempt to, as best they can, match the extensive resources available to the Commonwealth in defending the litigation. It remains to be seen whether legal aid will be forthcoming. In light of the recent budgetary reductions in legal aid and the fact that a Victorian firm was unable to obtain legal aid for their test case, we are not confident that such assistance will be forthcoming. The Victorian firm was unable to continue with the test case when legal aid was refused by the Commonwealth Attorney-General's Department. The decision not grant legal aid was made by the Commonwealth.

The litigation will be expensive, time consuming and complex. One can understand the genuine confusion shared by many recipients as they contemplate why it is even necessary to proceed through the Courts when two independent bodies have already condemned the program and the Department's and CSL's role in facilitating the debacle. In many respects we agree that it would be a tremendous waste of public resources to have a Court consider the issues again. However, if the Minister refuses to compensate injured recipients, litigation is the only alternative. The cost of litigation could be better served in compensating the recipients.

A summary of the more important findings of the Allars Inquiry and the Committee's Inquiry are enclosed. These findings, in addition to the material contained in the documents discovered to our clients by the Commonwealth and CSL during the course of the litigation, raise serious concerns about the acts and omissions of the Department and CSL in the past.

In short, the AHPHP was unlawful, ethical requirements were not observed and the authorities did not respond to the possibility of viral and slow viral contamination of the product. Arguably this tragic chapter in Australian medical history could of, and should have been avoided.

As a result of conflicting evidence given to the Senate Inquiry (including debate as to whether or not hormone contaminated with hepatitis virus was knowingly distributed by CSL for administration to recipients) the Committee recommended that Associate Professor Allars, or another suitably qualified person, be invited to review the additional material which had been forthcoming so that the findings of the Allars Inquiry could be reviewed and expanded upon.

The Committee heard evidence from a number of scientists, some of whom have perused the files and documents of the CSL and the Department. As noted in the Committee's Report, one scientist, a virologist, gave evidence to the Committee that:

"In relation to the CJD and hepatitis contamination of pituitary hormones, the failure of both CSL and HPAC to subject the gel chromatography technique to a very detailed critical analysis in relation to the possibility of contamination with viruses as a general problem, was, in my view, a major contributor to the disaster"

This evidence addressed the central argument of the Commonwealth which has been advanced to date, that is, the authorities believed at the time that the processing methods used by CSL would eliminate virus.

However, as this virologist properly points out, the ability of the processing to eliminate virus from the final product was never tested.

A CSL officer was asked, during the last day of public hearings, whether they were aware of the minutes of a meeting of the Fractionation Subcommittee (the 'FSC') in 1970 where the FSC conceded that there was no guarantee that virus would be eliminated during processing. It would appear that the discussion at this meeting undermines the Commonwealth's and CSL's argument that the processing method would eliminate virus. Curiously, the relevant CSL officer advised the Committee he was "not aware" of those minutes. Furthermore, the same officer also advised that he was "not aware" that the FSC also conceded that because exclusion criteria had not been complied with in the past, past batches of the hormones may have been contaminated with virus. Further evidence was given by the Department that there was no action taken to monitor the health of recipients to determine whether viral diseases were being transmitted to recipients via the hormone treatment.

It is clear that the Allars Inquiry was given, on a number of occasions, false and misleading information about material matters and that the Inquiry may not have been given all relevant information and documentation. Significantly, the Committee noted:

" ... the Committee considers that some of the information which came to light during the [Committee's] inquiry does raise serious concerns and warrants a further review. It also appears that some of this information was not available to the Allars Inquiry".

[emphasis supplied]

We are confident that overwhelming evidence can be presented to the Court that because of significant production and quality control difficulties (quite apart from the question of viral and slow viral infection), the hormones were not fit for use in humans and should never have been distributed. For example, one scientist, a former NBSL officer, gave evidence before the Committee that CSL's best hPG was 99.6% impure and that:

"It was a shocking product. I cannot believe that this could have been marketed".

[emphasis supplied]

Not only was it marketed, it was injected into human beings, who were used as human guinea pigs. This is most reprehensible conduct.

We are more than convinced that negligence can be proved in a Court of law, on the balance of probabilities, against the Commonwealth, the CSL and the medical practitioners who were responsible for the treatment our clients received. We are also confident that we can prove that our clients have suffered psychiatric injury as a result of their negligence.

In denying liability, the Commonwealth and CSL have relied upon an overly narrow interpretation of the common law as it relates to "nervous shock" claims. It is the opinion of this firm, and that of our two Counsel, one of whom is a Senior Counsel, that the common law accommodates these claims and provides for compensation to recipients.

Significantly, a number of other firms who have, or do act for recipients, in addition to their Counsel, are of the same view. The Commonwealth's and CSL's narrow interpretation of the law is even more curious when one considers that all, if not most, of the legal firms involved, and their Counsel, act for their recipient-clients on a contingency basis - an indication of ours and their belief that the recipients will be successful at trial.

Moreover, in 1995 the Commonwealth sought to strike out the proceedings commenced by a recipient in the Supreme Court of Victoria claiming there was no cause of action disclosed. His Honour Justice Harper delivered a judgment confirming that the common law could accommodate these claims and dismissed the Commonwealth's application.

One must also consider the judgment of the High Court in the United Kingdom last year, where it was found that the Defendants were negligent for the deaths of hGH recipients from CJD where recipients were treated after July, 1977. The Court's decision in this respect was based on the availability of knowledge on the transmissibility of CJD. That very knowledge was also available in Australia in widely read and prominent medical and scientific journals. We believe that while the Court's judgment is conservative it is nevertheless reassuring.

It is our opinion that there are no significant legal or evidentiary obstacles preventing injured recipients from obtaining compensation for their injuries from the Commonwealth and CSL.

When the Committee's unanimous Report was tabled in the Senate, Senator Brian Harradine (a Committee member) commented that:

"Our examination of the whole CJD episode provided a window into lax processes and cover-ups by those responsible for regulating human experimentation and by those whose grave duty it is to ensure the highest standards in the regulation and manufacture of biological products ... Women seeking help for infertility , and men and women of short stature were essentially guinea pigs in an unlawful experiment ... CSL did not meet the requirements of the Australian regulatory authorities ...There was enough information in 1966 to indicate that the program should not have been allowed to proceed"

[emphasis supplied]

The comments of the current Treasurer, the Hon. Mr. Peter Costello in 1993, are also significant and reflect the decision the Commonwealth ought to have made years ago. They also reflect the decision the Commonwealth ought to make now in light of the recent Report of the Committee:

" ... The Commonwealth can either spend its money on lawyers or on the victims. It will not necessarily be cheaper to spend the money on the lawyers; the Commonwealth will be paying which ever way it goes. As a matter of justice, it would be far more helpful to those who have suffered if the Commonwealth said that on this occasion its beneficence will be directed towards the victims, the families that have suffered the death and loss of a loved one, rather than the legal profession defending the claims ..."

[emphasis supplied]

Had the Department followed this advice in 1993 much anguish and anxiety in the recipient community would have been avoided. Ironically, many of the psychiatric injuries suffered by recipients could have been minimised or avoided instead of being aggravated. More importantly, significant public monies could have been better utilised compensating recipients instead of funding the Commonwealth's and CSL's vigorous defence of the proceedings. As the Report of the Committee indicates, the Commonwealth has not been the 'model litigant' it ought to be.

When one considers the comments of the then Chief Medical Officer of the Department in 1994, one wonders why the proceedings are being defended by the Commonwealth and CSL at all. In a current affairs program, Dr. Tony Adams made the following comments about the AHPHP and in doing so, made certain admissions:

"In many instances in the development of new therapies, people are used as guinea pigs, and unfortunately guinea pigs do not have a chance to give their fully informed consent as to what is being done to them...

... They were overenthusiastic, so some of the guidelines that were in place were either ignored or fudged

[in answer to the question "So patient's welfare was sacrificed?"] Unfortunately yes ...

Here was a situation that should have been corrected earlier than it was and people concerned both in Government and in the Committees who were handing out the hormones were derelict in their duty in not stopping it sooner"

[emphasis supplied]

The litigation commenced on behalf of our clients will continue if our clients are unable to obtain compensation for their injuries pursuant to the Committee's recommendations. The litigation will be extremely costly for all parties involved, It will be lengthy and time consuming and significantly demanding on the recipients who will continue. As the Committee noted:

"No doubt the costs and pressures of litigation have the potential to add greatly to the psychiatric stresses on recipients".

[emphasis supplied]

Ultimately it will be the tax payer who will bear the heavy financial burden if the litigation proceeds. In the event that our clients are unsuccessful, it is likely that the Commonwealth and the other Defendants will not be able to recover their legal costs pursuant to a costs order. Our clients are ordinary citizens. Many of our clients have few, if any, assets. In the event that our clients are successful, it will be the taxpayer who ultimately meets the tremendous legal costs which will be incurred by this, and possibly other legal firms.

There is no doubt that there will be further deaths of recipients in this country in the future. Over 100 deaths of recipients from CJD have been recorded world-wide. The remaining recipients now live with the constant reminder that they may have received contaminated injections and the knowledge of the possibility that they may develop and die from CJD at an unknown date in the future. There is currently no diagnostic tool available to determine those recipients who have received contaminated hormones and who will develop the disease. There is no cure. There is, at present, no apologies forthcoming from those who are responsible and certainly no acknowledgment that the authorities may have been derelict in their duty. There is currently no compensation for those who have suffered injury as a result of the negligence of others and those responsible are yet to be held accountable.

In the event that the Commonwealth compensates injured recipients pursuant to the Committee's recommendations, no binding precedent will be created. The argument of the Commonwealth that they can not compensate recipients as it would open a "flood gate" of claims against the Commonwealth is no basis for refusing to compensate recipients in these circumstances. When gross negligence and consequential injury has occurred, it is highly inappropriate for the Commonwealth to rely on groundless emotive rhetoric to deny compensation.

As the Federal Member of Hughes, we respectfully request that representations be made to the Minister of Health and Family Services on behalf of your constituents without delay. It is time the Department and CSL addressed the gross errors of the past by implementing the Committee's recommendations immediately, whether it be for moral or legal considerations.

Should you require any further information please do not hesitate to contact the writer or Mr. Macedone.

We look forward to your earliest reply.

Yours faithfully,