It is the second apology in two months from Monash IVF Melbourne. These major embryo mix-ups have caused immeasurable pain for these families and raised all sorts of doubts about the reliability of their fertility clinic. Today’s shitstorm is about the review conducted by barrister Fiona McLeod. In an investigation into a recent fatal collision in Brisbane, she found that it was due to human error. Monash IVF has chosen to maintain this review’s confidentiality. They highlight the need to safeguard the privacy of the patients studied. Our friends in Australia—specifically, the Australian Health Minister Mark Butler—beat us to it. He recommended Monash IVF to release the report’s findings to avoid any further erosion of public confidence from families around the country.
The embryo mix-ups were a catalyst for raising alarm bells about patient safety. Consequently Monash IVF has undergone significant leadership transformations. Following the exposure of the Melbourne incident in June, where a patient gave birth to a child that was not biologically related to her, CEO Michael Knaap resigned. Malik Jainudeen, the chief financial officer and company secretary, has taken over as acting CEO.
Recent Incidents Highlight Systemic Issues
Just recently in April 2023, one patient inadvertently ended up with the embryo of another woman. This blunder resulted in the delivery of a baby with no genetic linkage to her at all. This questionable arrest got much more complicated when another arrest came to light. In that case, a patient ultimately wound up receiving her own embryo, rather than the one intended for her partner. These blunders occurred at several levels because of human error and due to the lack of Monash IVF’s IT infrastructure.
Anastasia Gunn, whose family has been personally impacted by these tragedies, shared her anger toward the industry’s culture of secrecy.
“This is consistent for an industry that seems to thrive on secrecy and obfuscation to avoid true open disclosure.” – Anastasia Gunn
Together with Allied Health, FSANZ strongly supports these sentiments. They point out that although one of these events is a low probability high-impact event, when it happens, it is severe and needs to be addressed comprehensively. We have asked for a nationally consistent regulatory framework to govern this technology so it is conducted with rigorous accountability and transparency.
“The current patchwork of state-based regulation is no longer adequate,” – FSANZ
It is McLeod’s review that has most captured the public’s imagination. It raises broader questions about systemic governance failures of Monash IVF’s governance framework and clinical risk management.
Calls for Transparency and Accountability
Health Minister Mark Butler previously underscored Monash IVF’s responsibility in releasing the independent review. He hopes that this action will begin to restore confidence among the families who have entrusted their dreams of parenthood to the agency. So many families stuck in the wake of these blunders have been subject to tight NDAs. These agreements gag them and keep them from telling their story.
“To keep faith with families across Australia,” – Mark Butler
Advocates have long called for victims currently serving under NDAs to be granted amnesty. This would allow them to encourage firms to report errors voluntarily, without the fear of legal reprisals.
“There needs to be a temporary amnesty to victims bound by NDAs,” – Anonymous advocate
Stakeholders and investors have raised red flags about the lack of transparency that has come to define the incidents. The Australian Shareholders’ Association is calling for the full release of the McLeod review. They feel this transparency is key to identifying and addressing systemic issues.
“Without publishing the Fiona McLeod SC review in full, investors and stakeholders cannot be assured that systemic governance and risk failures have been addressed.” – Australian Shareholders’ Association
Moving Forward with Patient Trust
GWP Chair Malik Jainudeen has spoken out on the pain these events have caused. He publicised that Monash IVF is currently taking steps to improve its processes and accountability to prevent such incidents from occurring.
“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,” – Malik Jainudeen
Monash IVF is going through a stormy period. It is coming under a new wave of pressure from state and federal government officials and patient advocacy groups to do so. These confusing errors impact more than just one family. They expose deep systemic problems in the fertility industry that should be addressed immediately.
