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21 December 2011

Summary of request

The Authority was asked for information about any errors made at hospitals (NHS and private) in Wales during the last 5 years and whether any hospital has reported no errors.

HFEA response

It may help to give some background to explain the type of information that the Human Fertilisation and Embryology Authority (HFEA) holds with regards to errors at hospitals in Wales. The HFEA licenses UK centres that carry out fertility treatment so, any hospital carrying out, for example IVF, must have an HFEA licence. For more information about exactly what we license please see our website: http://www.hfea.gov.uk/121.html . The HFEA currently licenses seven centres in Wales and more information about each of these can be found via a search by region of our online clinic directory at: http://guide.hfea.gov.uk/guide/ .

Under the HFEA’s General Directions 0011, centres licensed by the HFEA must report adverse incidents and near misses to the Authority. The Directions set out the type of incident that must be reported and a copy of them can be found here: http://www.hfea.gov.uk/188.html . Reported incidents are categorised by the Authority as A-C or a ‘near miss’, the most severe being A.

The HFEA does not therefore hold the total number of errors made at hospitals, however, it does hold the number of reported incidents as defined by General Directions 0011. The document attached sets out the number of incidents reported by HFEA licensed centres in Wales to the HFEA during the last 5 calendar years, a total of five centres licensed during this period did not report any incidents. Please note that the number of centres and treatments will vary year to year, which may influence the number of incidents reported.

An example of a grade B incident is a case of severe Ovarian Hyper Stimulation Syndrome and an example of a grade C incident is a routine testing of an alarm highlighting that a link was not working to the hospital’s switchboard. The data shows an increase in the number of B and C grade incidents being reported. HFEA licensed centres are encouraged to recognise and report when things go wrong, by doing so they can improve their processes. We welcome the fact that clinics are reporting more incidents and the sector has responded positively to the opportunity to share lessons learned from incidents that have been reviewed and investigated.

In 2010 there were more than 60,000 cycles of IVF, ICSI and DI which entails hundreds of thousands of laboratory procedures. Whilst we take each reported incident seriously and investigate thoroughly, the total number of incidents represents a tiny percentage of all procedures taking place.

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Page last updated: 16 August 2012

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