Monash blames ‘human error’ for embryo mix-up but keeps review under wraps
The Brisbane woman who gave birth after being implanted with another couple’s embryo was failed by ‘human error’, says Monash IVF.
Monash IVF has blamed “human error” after it mistakenly implanted a stranger’s embryo into a Brisbane woman, causing her to give birth to another couple’s child – with the company now refusing to release its review into the scandal.
The nation-leading medical firm said its commissioned review from Victorian commercial lawyer Fiona McLeod SC would be withheld from the public “ to protect the privacy of the affected patients”, only saying that the “Brisbane incident” revealed in April and another scandal in Clayton reported in June were the products of “human error at multiple stages”.
The Brisbane mix-up was the first of its kind in Australia and only came to light after it was reported in the media, in a “distressing” mistake that was not discovered for at least five months, and after the baby was born. Two months later Monash IVF revealed it had mistakenly transferred the wrong embryo into another patient in Clayton.
“The independent review is a comprehensive examination of both incidents, which were unrelated, different in nature and occurred some years apart. Both cases involved non- standard IVF treatments and circumstances that would not arise in the vast majority of IVF procedures,” Monash IVF said in a statement to the ASX.
“The independent review concluded that the Brisbane incident was the result of human error. The Clayton incident resulted from a range of factors that included human error at multiple stages and IT system limitations in the very limited circumstances of an embryo transfer to a partner. Those limitations ultimately made subsequent processes more vulnerable to human error.”
The successive failures at Monash IVF provoked industry-wide scrutiny and commitments to federal, state and territory legal reform.
“To the affected patients and everyone who entrusts Monash IVF with their dreams of building a family, we are deeply sorry for the distress these incidents have caused,” Monash IVF acting chief executive Malik Jainudeen said.
“We have implemented or will be implementing the recommendations of the independent review and have taken additional measures to reduce the risk of such incidents occurring in the future because the care and safety of our patients is and will always be at the heart of everything we do.”
The company has blamed human error since the mistake first came to light.
“The human error was identified … following the birth parents requesting the transfer of their remaining embryos to another IVF provider. Instead of finding the expected number of embryos, an additional embryo remained in storage for the birth parents,” a statement released by Monash IVF said in April.
“The investigation confirmed that an embryo from a different patient had previously been incorrectly thawed and transferred to the birth parents, which resulted in the birth of a child. The investigation also found that despite strict laboratory safety protocols being in place, including multi-step identification processes being conducted, a human error was made.”
The clinic did not identify either of the couples involved or say which family the infant was living with. Both families were reportedly mulling legal options in the aftermath.
Monash IVF will front up to investors on Friday, announcing its FY25 results.