Human error blamed for two embryo mix-ups but details kept secret

A review into embryo mix-ups at Monash IVF clinics in two states has found that both incidents were the result of human error.

An independent review commissioned by the IVF giant into two cases of patients being implanted with the wrong embryos has found that although there were stark differences in the circumstances of the bungles at its Brisbane and Clayton clinics, human error was at the heart of both incidents.

In an announcement to the Australian stock exchange on Wednesday, Monash IVF confirmed Fiona McLeod, SC, had completed her look at the incidents and made a range of recommendations that would be implemented.

The company initially commissioned McLeod to conduct an independent investigation on March 4, after revelations emerged in April that an embryo transfer error at its Brisbane facility resulted in a Queensland woman giving birth to a stranger’s baby.

Within two months the company asked McLeod to expand the review after they admitted a woman had been implanted with the wrong embryo during a procedure at its Clayton clinic on June 5.

In its notice to the ASX, Monash IVF said the review found that the two incidents were unrelated, different in nature and occurred years apart. It found that both of the cases involved non-standard IVF treatment and circumstances that would not typically arise in the majority of procedures.

It said McLeod had found that the Brisbane incident was the result of human error alone.

She found that the Clayton mix-up resulted from a range factors, including human error at multiple stages, as well as limitations in the IT system. The review found that those limitations ultimately made the transfer process more vulnerable to human error.

However, Monash IVF has not released the full details of the review’s findings, nor its recommendations, claiming it is to protect patient privacy.