91Èȱ¬

A whistleblower who worked at one of the country's leading fertility clinics has spoken for the first time about the failure of safety procedures there.

Clinical embryologist Bea Pavlovic says she warned her bosses at the NHS Guys and St Thomas's hospital as early as 2004 that procedures were not being followed properly. Earlier this year there was a serious mix-up there when eggs were fertilised with the wrong sperm.

In January 2004, Bea Pavlovic was on administrative duties and responsible for patients' records. She told 91Èȱ¬ Radio 4's The Report that she became concerned when she noticed that paperwork relating to a safety procedure, called witnessing, had not been properly filled in.

Witnessing is a process whereby two embryologists have to observe and double check every time a procedure is carried out, such as changing a petrie dish or even placing an embryo back in the freezer. Then both embryologists are supposed to sign a form contemporaneously, so that there is a clear record of what was done and when.

Ms Pavlovic said: "There were numerous errors. But basically of the same kind, which referred to witnessing procedures. There were missing signatures on one procedure or another. Or sadly actually there were missing signatures on a whole procedure."

She added that the witnessing procedure was essential: "Witnessing is in place to show that the right eggs, the right sperm, the right embryos have been used correctly. I have no words to explain how important that is. My first duty is to report this to my seniors. And this is exactly what I did."

She said that when she raised her concerns with managers: "I've been referred to as a broken record."

Ms Pavlovic took her concerns to the regulator, the Human Fertilisation and Embryology Authority.

She was later dismissed from her post for potentially breaching patient confidentiality. She admits she did take copies of some patients' records home to keep as evidence.

But the 91Èȱ¬ has seen documents regarding a professional hearing into her conduct which took place last year. The panel found she had acted in the "interests of the patients and of the clinic". It also said it found "a clear indication of systemic shortcomings in the completion of documentation which had the potential to increase the risk of an error being made in clinical procedures".

Ms Pavlovic said she felt vindicated by the decision and earlier this year it was revealed there had been a mix-up at Guys. In the case of two couples the wrong sperm was injected into the wrong eggs.

The Guys and St Thomas's Assisted Conception Unit said in a statement: "We have already acted to minimise the risk of similar incidents happening again. Since these incidents took place, our Assisted Conception Unit has moved to a £4.2m state-of-the-art new unit, which provides added assurance that patient samples are always handled separately. We have also introduced an electronic tagging system as an additional layer in our witnessing process to guard against human errors.

"We are working with the HFEA to see what else we can do to further improve the safety of our processes. If further changes need to be made, we will make them."

Notes to Editors

Witnessing was brought in as a result of another incident in a Leeds clinic in 2002 when a white woman gave birth to mixed-race twins after her eggs were fertilised by the wrong sperm. It is designed to stop mistakes being made due to human error and all clinics are required to do it.

The Report, 8.00pm, Thursday 27 August 2009, 91Èȱ¬ Radio 4

Any use of information from this release must be attributed to "91Èȱ¬ Radio 4's The Report".

FS