IVF Clinic Admits Mix-Up Led To Embryo Being Given To Wrong Woman

Couple Awarded Compensation For Medical Negligence


IVF Clinic Admits Mix-Up Led To Embryo Being Given To Wrong Woman

A Bridgend couple have spoken of their heartbreak after an IVF clinic mix up led to their embryo being wrongly transplanted into another patient.

The blunder at the Cardiff-based University Hospital of Wales' IVF clinic was discovered when the couple attended the clinic for the implantation of their last remaining viable embryo, only to be told that there had been 'an accident in the laboratory.' The couple was later informed that the patient who had wrongly been given their embryo had, on being told of the error, decided to terminate the pregnancy.

Cardiff and Vale NHS Trust have now admitted liability for gross failures in care resulting from the incident which happened in December 2007 and agreed to pay an undisclosed settlement to the Bridgend couple – Deborah and Paul - who have requested their full names remain anonymous.

The couple's solicitor, Guy Forster, from national law firm Irwin Mitchell, described the mix-up as "an accident waiting to happen," following the revelation that there had been two previous near misses at the clinic.

Deborah and Paul were originally referred to IVF Wales (then 'Cardiff Assisted Reproduction Unit') after an ectopic pregnancy in 1996 caused damage to Deborah's fallopian tubes. In 2000 the couple commenced fertility treatment.

Following the third cycle of treatment, Deborah became pregnant and in April 2003 gave birth to a son.

The remaining embryos were frozen and, in line with the clinic's policy, were kept for five years. In November 2007 the clinic contacted the couple with the news that just one embryo had survived and was in good condition. Deborah, who was now 38 years old, and her husband, Paul, decided to take this last chance to add to their family and have a much longed for brother or sister for their son who was then aged four.

On 5 December 2007, the couple attended the clinic for the embryo to be transplanted, unaware that in the laboratory a trainee embryologist had mixed up their embryo after taking it from the wrong shelf of the incubator. Against all guidance, more than one patient's embryos were being temporarily stored in the incubator.

The trainee embryologist failed to carry out 'fail-safe' witnessing procedures to ensure the embryo being taken from the incubator and implanted, belonged to the correct patient. The mistake was only discovered when another colleague later found that Deborah's embryo was missing from the incubator. The Human Fertilisation and Embryology Authority (HFEA) was informed of the incident.

Deborah explained: "I will never forget the moment the hospital broke the devastating news to us. I just could not believe what I was hearing. Initially the hospital staff told me there had been an accident in the lab and that the embryo had been damaged, I thought that someone had perhaps dropped the embryo dish.

"I remember thinking, 'That's our last hope gone – we will never have another child.' I left the hospital feeling totally shell-shocked.

"When we went back to the hospital two days later and we were told the truth about my embryo being given to someone else; I was so angry.

"I had been given a handbook before every course of IVF explaining all the elaborate precautions the clinic undertook to ensure this sort of mix-up was impossible – and yet despite everything, it had still happened."

Guy Forster, a medical negligence expert with Irwin Mitchell solicitors, who represented Deborah and Paul, said: "A report by HFEA investigators shows that the error occurred primarily due to failures by laboratory and theatre staff to carry out basic procedures. However, it is clear that there were a number of system failings, in that the Clinic had failed to implement the procedures set out in the HFEA's Code of Conduct, workloads were above safe levels and there were staff shortages.

"IVF Wales reported two 'near miss' incidents to the HFEA in 2006 and an HFEA inspection in February 2007 had warned the Clinic to tighten its witnessing procedures, yet it would seem nothing was done. This was an accident waiting to happen."

An independent inquiry into failings at a Leeds IVF unit in 2002 led to a series of recommendations being made to the HFEA and all fertility clinics to safeguard against this type of incident in the future. The HFEA's effectiveness to act as a watchdog has recently been questioned by the head of that inquiry, Professor Brian Toft, following recent reports of IVF mistakes in London in February 2009.

Guy Forster added: "We are concerned that the HFEA missed opportunities to take action in relation to IVF Wales before this incident occurred.

"Although such incidents are thankfully rare, couples undergoing IVF treatment need to have complete confidence that failsafe procedures are not only in place but, more importantly, are being carried out at all times. We can only hope that both the NHS and HFEA will have learned lessons from this appalling error."