A BABY was born with cystic fibrosis after failings by the Frimley Health NHS Foundation Trust and a private IVF clinic, an investigation by the Human Fertilisation and Embryology Authority (HFEA) has found.
The investigation concluded that the trust mis-reported screening results for cystic fibrosis, declaring them as normal, before sending them to a Woking-based private clinic which was treating the couple.
Their consultant at Nuffield Health Woking Hospital did not read the test results, which were left stapled to the back of a letter that wrongly claimed the child’s parents were not carriers of the condition.
Cystic fibrosis is an inherited condition in which the lungs and digestive system can become clogged with thick, sticky mucus, resulting in a reduced life expectancy.
If the genetic mutation had been detected, the embryos could have been screened to select one free of the faulty gene. The error was only discovered after the child was born and found to have cystic fibrosis.
The 2016 case was identified in the HFEA’s first ‘state of the sector’ report as the only ‘grade A’ incident out of a total of 540 adverse incidents last year, meaning it involved severe harm to one person or major harm to many.
The report concluded the screening results were “not properly read by the treating clinician, nor signed and transposed into the patient’s medical record”, and criticised the lack of a “robust system” to ensure reports are reviewed before being read.
Responding, the HFEA demanded changes by the clinic and NHS trust to prevent future errors, including measures to ensure all abnormal results are reviewed by the treating clinician.
A spokesperson for Nuffield Health said: “We deeply regret this sad incident. We have offered our most sincere apologies and are providing ongoing support to the couple and their child. We have reviewed our processes and have taken steps to ensure this should never happen again.”
A spokesman for Frimley Health NHS Foundation Trust added: “After recognising that a serious incident had occurred we worked closely with the family and the Nuffield to find out exactly what happened and how risks could be minimised in future.
“As a result of the investigation we implemented a number of actions. The most important and urgent of these was a review of current job plans for clinicians that undertake fertility outpatient clinics to ensure they have sufficient time to fully review results.”
More than 76,000 cycles of IVF were carried out in 119 licensed fertility clinics across the UK in 2016/17. Three in five treatments were paid for by patients themselves.
Sally Cheshire, chairman of the HFEA, said: “While the number of incidents and non-compliances must be placed in the context of the many thousands of treatments being performed in the UK each year, the fact is that all incidents, whatever the category, can be very upsetting for patients and must be avoided wherever possible.”