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An independent review by Monash IVF Group (ASX: MVF) of two separate incidents of embryo mix-ups in Brisbane and Melbourne have found human error and IT system limitations as causes for the failures.
While the full report prepared by Fiona McLeod SC is not being released publicly to protect the privacy of the affected patients, Monash IVF says both cases involved “non-standard IVF treatments and circumstances that would not arise in the vast majority of IVF procedures”.
The first incident was exposed in a media report in April which involved the embryo of one patient being incorrectly transferred to another patient which led to the birth of a child.
Monash at the time said it became aware of the incident in February this year with its preliminary finding also revealing a case of human error.
The second incident occurred at the company’s Clayton laboratory in Melbourne on 5 June, when a patient's own embryo was “incorrectly transferred to that patient, contrary to the treatment plan which designated the transfer of an embryo of the patient's partner”.
Monash IVF instigated an independent review of its systems following the embarrassing revelations which the company says are “unrelated, different in nature and occurred some years apart”.
The company says that the independent review concluded that the Brisbane incident was due to human error, while the Clayton incident was caused by a range of factors including “human error at multiple stages and IT system limitations in the very limited circumstances of an embryo transfer to a partner”.
“Those limitations ultimately made subsequent processes more vulnerable to human error,” says the company.
Monash IVF says it has already implemented many of the review’s recommendations, adding that following its own internal review it has also implemented additional safeguards and protocols.
“These additional safeguards and protocols go beyond the recommendations contained in the independent review,” the company says, while adding that it is committed to implementing all of the recommendations made by McLeod in her independent review.
Monash IVF says the costs of the new measures are not expected to have a material impact on the group’s financial performance, although the group previously announced a profit downgrade in April following softer market conditions in March and April this year.
“To the affected patients and everyone who entrusts Monash IVF with their dreams of building a family, we are deeply sorry for the distress these incidents have caused,” says Monash IVF’s acting CEO Malik Jainudeen.
“We have implemented or will be implementing the recommendations of the independent review and have taken additional measures to reduce the risk of such incidents occurring in the future because the care and safety of our patients is and will always be at the heart of everything we do.
“For more than 50 years, MVF has been there for patients through more than 50,000 births and we look forward to continuing to support families with their fertility journey.”
Shares in Monash IVF were trading 1.75c higher at 82.75c at 11am (AEST).
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