Jun 23 2004
The report was commissioned by the Chief Medical Officer in response to a series of four adverse incidents that occurred in the Medical Reproduction Units at the Leeds Teaching Hospitals NHS trust, West Yorkshire, before July 2002. It is clear from the report that these incidents were caused by a combination of human error and weaknesses in risk management at the time. It is the clinics responsibility to make sure systems are in place to minimise risk to patients. It is the HFEA’s responsibility, as the regulator, to check these systems to help clinics minimise human error in the practice of licensed fertility treatments.
Since the incident in Leeds, the HFEA has changed the way it works and has already put in place over 85% of Professor Toft’s proposals. These include:
- Introducing double checking of patient identification at all stages of treatment
- Setting up an alert system to ensure timely investigation of all incidents and the sharing of information on lessons learnt to all clinics in the UK
- Introducing unannounced inspections of clinics
- Improving selection, training and accreditation of external inspectors and staff
- Designing a new Code of Practice for clinics, setting out required standards of practice
- Including patient feedback in the inspection process
- Angela McNab, HFEA Chief Executive, says:
“Protecting patients is the top priority for every member of staff at the HFEA. We are continuing to work with clinics, healthcare professionals and of course patients to maintain the highest possible standards of care. The UK has the toughest regulation of fertility clinics anywhere, and patients can be confident that their fertility treatment is the safest in the world.
Over the past two years the HFEA has modernised and strengthened regulation supported by government increases in resources.”
Suzi Leather, HFEA Chair, says:
“This mistake has caused great emotional turmoil and pain. We owe it to every patient and every baby born to make sure that the HFEA is doing everything possible to minimise the risks. Like other areas of medicine it is not possible to eliminate all risks, but we have improved safety in clinics and this will continue. I’m pleased that the significant progress we have made has been recognised in this report.”