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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Deputy Health and Disability Commissioner Rose Wall today released a report finding Fertility Associates Holdings Limited in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of a woman undergoing a cycle of IVF.
A blood test was taken to determine whether or not the woman was in the correct stage of her menstrual cycle to begin an IVF cycle. The woman’s progesterone result was found to be higher than expected and indicated that she might already have been pregnant.
While some of the results of the blood test were relayed to the on-call doctor who was making the decision on whether it was appropriate to begin the IVF cycle, the progesterone result was not seen by any of the clinical staff at this time.
The on-call doctor gave approval for the woman to start medication for her IVF cycle and she commenced treatment. After taking the prescribed medication for ten days, it was discovered that the woman was pregnant.
The woman and her husband subsequently contacted Fertility Associates outlining their concerns that treatment had been provided while the woman was pregnant. Fertility Associates responded to these concerns but did not mention the woman’s high progesterone level and failed to provide her husband with the result from this blood test when he requested a copy of all blood test results.
The Deputy Commissioner found Fertility Associates in breach of the Code for wrongly starting the woman on an IVF cycle contrary to her progesterone test result.
Ms Wall was also critical of Fertility Associates’ disclosure of the error with the family. She noted that a thorough investigation of what had occurred, and full open disclosure of the error, was not undertaken until the woman and her husband complained to HDC.
“This case highlights the importance of robust test ordering protocols and effective communication between providers to ensure quality of services, as well as the importance of openly and honestly disclosing information about errors that occur during the provision of a healthcare service,” Ms Wall said.
Ms Wall recommended that Fertility Associates provide evidence that its new test ordering protocol has been incorporated into its policies and procedures; undertake an audit of staff compliance with its new test ordering protocol; provide evidence of the ongoing education provided to its staff; and consider whether any of the learnings and changes made in response to this investigation can be translated into improvements throughout its other Fertility Clinics.
She also recommended that they review HDC’s Guidance on Open Disclosure Policies and identify areas for improvement in its practice, and use this to create a policy on open disclosure; consider collaborating with other fertility service providers in New Zealand to ensure that its current test ordering protocols are consistent with sector-wide best practice; and provide the woman and her family with an apology.
The full report on case 19HDC00584 is available on the HDC website