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Fertility clinics blasted for failings
Mike Waites, Health Correspondent A DAMNING report has uncovered serious failings in the running of fertility services across the country in the wake of a mix-up in Yorkshire which led to mixed-race twins being born to a white couple.
Today's report – a copy of which has been obtained exclusively by the Yorkshire Post – makes more than 100 recommendations for change.
It creates a picture of inadequate regulation of the country's 90 in vitro fertilisation (IVF) units, which has compromised safety.
The Government is blamed for cash cuts that have undermined the work of the regulator, the Human Fertilisation and Embryology Authority, which is accused of operating "a culture of secrecy" under which lessons have not been learned from mistakes.
The landmark 180-page report also calls for changes in the running of the fertility unit at Leeds General Infirmary where the error was made.
It reveals for the first time the likely cause of the mistake at the internationally respected centre when sperm samples from two different donors were mixed up.
But it concludes that the misidentification of patients by staff at IVF units across the country "is not a new phenomenon", raising the likelihood other similar errors have gone unnoticed.
The report will be highly embarrassing for Ministers who are publishing it without fanfare later today even though it was received as long ago as November.
A total of 70 findings relate to the HFEA, which is also criticised for initially failing to co-operate with the inquiry.
In the long term, the report will be influential in making major improvements to the quality of IVF units across the country ahead of a significant expansion of services due when the NHS routinely funds infertility treatments for the first time.
Its author, leading risk analyst Prof Brian Toft, says a number of weaknesses were identified.
"IVF techniques have brought happiness for numerous couples over the past 20 years or so. However when an adverse event takes place it can have a devastating effect upon all those involved," he says.
"It is therefore crucial that society learns from such incidents and so far as it is possible attempts to make sure they do not recur. This report is a first step in that process."
He found that the HFEA had been unable to cope with the huge advances in fertility treatments in the last 15 years.
It had been forced by the Government to make major cuts which had meant "a less robust approach to inspections" of IVF units had been introduced in 1999.
The authority had failed to use its powers to insist on changes at fertility units and had developed a "culture of secrecy" which had prejudiced its ability to carry out its duties in an "open and effective way".
Even its own staff were not told about mistakes while the authority had issued no guidance about how they could be avoided.
Supervision of its activities by Ministers and officials had also proved inadequate.
He blames the mistake at the Leeds unit for a mixture of "inadvertent human error and systems failure".
"In this case, we concluded that it was impossible to say with certainty at what point in the process the misidentification of sperm had occurred," he said.
"However a number of weaknesses were found in the practices and protocols used in the embryology laboratory."
He said both the fertility unit in Leeds and the HFEA had made significant progress since he had begun his investigation two years ago.
He pays tribute to staff in Leeds for the "forthright" way they had responded to the investigation. Many of his recommendations for the unit have been implemented.
The report also reveals for the first time that two other mistakes were made at Leeds General Infirmary which led to 11 eggs being inseminated with the wrong sperm and seven embryos being accidentally destroyed. A fourth mistake in the fertility unit at St James's Hospital in the city led to six embryos being destroyed against the wishes of the parents.
mike.waites@ypn.co.uk
Fall in standards blasted: Page 4
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Saturday 26 May 2012
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