A couple's hopes of having a second child after IVF treatment were dashed when their last embryo was mistakenly implanted into another woman by an overworked trainee doctor. The woman mistakenly given the embryo, which was the last of nine the couple had had created by IVF, decided to abort the foetus.
An urgent investigation by the Human Fertilisation and Embryology Authority (HFEA) found that stringent safety checks which require all procedures to be witnessed and verified had not been carried out and staff were under pressure to clear a backlog of cases.
The incident happened at IVF Wales Clinic, part of Cardiff and Vale NHS Trust, where it has emerged that the HFEA had previously been told of two other "near misses", also believed to involve failures in ensuring procedures were properly witnessed by other staff.
The couple, from South Wales, had been together 20 years and, unable to conceive naturally, spent years on the NHS waiting list for fertility treatment. In 2000, they created nine embryos using IVF, and after two rounds of treatment, had a son in 2003. The remaining two embryos were kept in deep storage.
They embarked upon a further round of treatment after the clinic contacted them in 2007 to inform them that one of the embryos was still in good condition, they told the Mail on Sunday. But when they went to have the embryo implanted in December 2007, they were first told that it was "no longer viable", following an accident in the laboratory. The next day they were told that it had been given to the wrong person by a trainee embryologist.
The woman, 38, told the paper: "In less than 10 seconds our wonderful world was shattered. But even our worst fears didn't prepare us for the devastating news that our embryo had actually been placed in another woman, and that it had to be taken out and destroyed for 'medical reasons'.
"We were shaking with shock and bursting with anger, especially as it was the one thing all IVF patients are told could never happen. What's more, although it was the last of our embryos and although they offered another round of IVF treatment for free, we turned it down, and made it plain that we would never trust them again."
The error was uncovered when staff realised the trainee embryologist had been alone when she removed the embryo from the incubator. Normally, two people should check its identification and document having done so – a procedure that should be repeated at the implantation stage.
The HFEA found that laboratory and operating-theatre staff had failed to carry out basic procedures. Staff shortages were a contributory factor. Cardiff and Vale Trust held its own inquiry at the same time. The trust has admitted liability for the incident and paid the couple a five-figure sum, believed to be £25,000.
The trainee has not been named, and the clinic has not confirmed if she is still working there or if disciplinary action has been taken against her.
The clinic cut the number of IVF procedures it performs from 570 two years ago to 427 last year. In its last inspection in July 2008, the HFEA concluded the unit had made improvements.