IVF baby given to wrong woman was an accident waiting to happen

A solicitor representing an IVF couple whose last embryo was wrongly implanted into another patient has described the clinic mix up as an “accident waiting to happen”.

The couple have spoken of how their lives were “shattered” when the University Hospital of Wales’ IVF clinic in Cardiff discovered the error.

They were further distressed when they learned the other woman had chosen to have a termination.

The Cardiff and Vale NHS Trust has apologised for the blunder and paid the couple an undisclosed sum in damages.

The woman said: “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. “

The couple’s solicitor, Guy Forster, from the firm Irwin Mitchell, said there had been two previous “near misses” at the clinic the year before.

The couple were originally referred to IVF Wales after an ectopic pregnancy in 1996 caused damage to the woman’s fallopian tubes. The couple began fertility treatment in 2000.

Following the third cycle of treatment, the woman 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. The woman, who was then 38, and her husband decided to take “this last chance” to add to their family, Mr Forster said.

The couple, named by Mr Forster only as Deborah, a health care assistant, and Paul, a printing firm supervisor, from Bridgend, south Wales, attended the clinic on Dec 5, 2007, for their final embryo to be transplanted.

They were told a trainee embryologist had mixed up their embryo after taking it from the wrong shelf of the incubator.

Mr Forster said that 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, he said.

The mistake was only discovered when another colleague later found that Debroah’s embryo was missing from the incubator.

Mr Forster said: “A report by the Human Fertilisation and Embryology Authority showed 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.”

Ian Lane, the health trust’s medical director, said: “We apologise unreservedly for this mistake.


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