The issuing of Dame Butler-Sloss's statement comes just one week after another IVF embryo mix-up was revealed at a London hospital. Two women receiving fertility treatment at St George's Hospital were implanted with the wrong embryos in April, but the mistake was noticed promptly and the women were recalled for treatment to prevent pregnancy.
The hospital has since said that a labelling error was responsible for the mistake. Professor Paul Jones, the medical director of St George's, said that following an internal enquiry, it was shown that a lack of staff meant that the required procedural checks had not always been carried out. He said 'the unit was full of very able, excellent people but it was very badly organised'. He added that the error 'wasn't a result of people behaving in a negligent manner, it was the result of an accident happening in an environment that permitted it to go that way'.
Professor Jones went on to say that the internal investigation of the unit had showed that the clinic was 'chaotic', its leadership was 'both poor and autocratic' and that a 'culture of blame' had developed. The clinic has since closed due to its lack of finances and a failure to recruit more staff.
Some fertility experts have called for the Human fertilisation and Embryology Authority (HFEA) to tighten its guidelines in order to prevent embryo mix-ups happening again. Ian Craft, director of the London Fertility Centre, said 'it's not the first time this has happened, and I think the HFEA should set out a protocol to prevent it from happening again'. But Simon Fishel, of CARE fertility clinics said 'however good the regulation system, however consistent the practice, you can't 100 per cent guarantee that there can never be a human error'.
Sources and References
Staff shortage blamed for IVF mix-up
Staff shortage led to embryo mix-up