Jun 23 2004
The Department of Health today published its report into the circumstances surrounding the IVF mix-up that led to mixed-race twins being born to a white couple.
Chief Medical Officer, Sir Liam Donaldson, commissioned Professor Brian Toft to investigate the circumstances surrounding the adverse events that had occurred at the Medical Reproduction Units at the Leeds Teaching Hospitals NHS trust, West Yorkshire.
Professor Toft's report describes the background against which the events occurred and examines what weaknesses and vulnerabilities existed at that time. The report concludes that the events were caused through a mixture of inadvertent human error and systems failure.
The report includes recommendations to the Department of Health, the Human Fertilisation and Embryology Authority (HFEA) and Leeds NHS Trust but Professor Toft makes clear that significant progress has already been made since the events occurred.
Chief Medical Officer, Sir Liam Donaldson, said:
"I'd like to thank Professor Toft for preparing this thorough report. The mistakes detailed in this investigation were enormously distressing to the patients involved and their families. Lessons will be learned from what happened so that we can reduce the chance that anything like this will happen again.
"Patients undergoing assisted conception treatment should feel confident in the services provided. Professor Toft's report contains some practical and achievable recommendations. I understand that improvements to address these recommendations have already taken place at both the HFEA and the Leeds Trust."
Professor Toft said:
"The starting point for this review was that patient safety is paramount. Patients need to be confident in the assisted conception treatments they are receiving
"During this review we identified a number of potential vulnerabilities and weaknesses in the regulatory procedures and clinical systems that were in place when the incidents occurred. The review panel has made a number of recommendations to address these. However, it is important to bear in mind that these events occured before July 2002. Both in the course of the review and since, the HFEA and the Leeds Trust have been addressing the concerns identified and I am confident that they are putting in place the necessary arrangements to make significant progress."