‘Huge system failure’: Parents reeling after vaccine storage error at Sydney GP clinic

A vaccine storage error at a general practice in Sydney’s inner west may have left more than 1000 patients, including infants and children, without protection against serious diseases over the past five years.

The Holy Family Medical Centre in Dulwich Hill sent letters to patients this week advising that vaccines they were administered may have been stored at incorrect temperatures, rendering them ineffective.

A NSW Health fact sheet included with the practice’s letter said parts of its vaccine management between 2019 and 2024 didn’t follow the National Vaccination Storage Guidelines.

The Holy Family Medical Centre at Dulwich Hill.Credit: Google

“Unfortunately, we can’t say exactly which, if any, vaccinations may have been affected,” the letter read.

The letter said receiving an ineffective vaccine was not harmful but was “the equivalent of not being vaccinated”.

“This means you remain vulnerable to serious diseases like polio, hepatitis, measles, whooping cough and pneumonia that remain threats to our community,” it read.

One mother who received the letters said her two children’s entire vaccination history had been affected.

“I’m sick to my core,” said the mother, who requested not to be identified to protect the privacy of her children’s medical history.

Both her children were premature and growth-restricted, and had spent time in neonatal intensive care units after birth.

“I’m just reeling with ‘what ifs’. I thought that they were protected, and now there is a chance that they’re almost completely vulnerable,” she said. “I have no idea if my immunocompromised kids are protected against everything, one thing or nothing at all.”

Her son has autism spectrum disorder and would need support from an occupational therapist to receive another eight needles. “He will lose his mind,” the mother said.

Several other parents who received the letters expressed dismay that the vaccine storage and handling systems were not monitored appropriately to prevent temperature breaches.

A NSW Health source familiar with the case but unauthorised to speak publicly confirmed the clinic had contacted around 1200 potentially affected patients, 394 of whom were children under the age of five.

Australian Primary Health Care Nurses Association president Karen Booth said children would be particularly affected because they were likely to have been given all their crucial childhood vaccines at the same clinic.

“This is a huge system failure,” she said. “There’s no excuse … it’s a product that’s supplied free by the government for [the clinic] to supply, and part of the agreement to have vaccines is that you will manage the cold chain.”

The Holy Family Medical Centre declined to comment.

Under NSW Health guidelines, vaccines must be stored within 2 to 8 degrees at all times in purpose-built vaccine refrigerators, which must be continuously monitored on a data logger.

Temperatures should be checked twice daily, and immunisation providers must conduct vaccine storage self-audits at least every 12 months.

‘I have no idea if my immunocompromised kids are protected against everything, one thing or nothing at all.’

A mother whose two children received vaccines at the clinic

NSW Health established an expert panel to review the situation, which determined the possibility of less-than-effective vaccines could not be overlooked.

Because it was not possible to identify which vaccines were affected, the panel recommended all patients who received vaccines at the practice between December 4, 2019, and July this year be revaccinated.

Sydney Local Health District is helping the practice set up a special clinic offering free additional vaccines for those affected. A spokesman said revaccination would not be harmful, even if the first immunisation was effective.

In 2019, two Sydney GPs were found to have administered expired or poorly stored vaccines to as many as 3000 patients – including infants and young children – over almost nine years.

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