Select Committee on Science and Technology Minutes of Evidence

Examination of Witnesses (Questions 380 - 399)



  Q380  Dr Harris: Was it your understanding that your findings would be made public?

  Professor Toft: Indeed, it was, yes.

  Q381  Dr Harris: But I understand there was a long period of time between submitting your report and its publication. Why was that?

  Professor Toft: I could not say. You would have to ask the Department of Health that.

  Q382  Dr Harris: Was there a problem with regard to publishing your report?

  Professor Toft: As far as I am concerned, Dr Harris, there was not a problem with the report. I submitted it to the Chief Medical Officer; it took time for them to make up their mind as to whether they were going to publish it or not.

  Q383  Dr Harris: Was it your understanding at the outset that it would be published?

   Professor Toft: My understanding was that it might be published or that it could be published.

  Q384  Dr Harris: Rumours that it was nearly not published and that there needed to be a legal opinion before it was published were nothing to do with you. As far as you knew, you did a report, you were not sure whether it was going to be published, you submitted it, and then it was out of your hands. Or did you retain an interest in whether your work would see light of day publicly?

  Professor Toft: Obviously I had an interest in whether it was going to see the light of day. I understood from formal conversations that a legal opinion had been sought, but I was under the impression that because of the act itself one has to be extremely careful: if you reveal anything, even inadvertently, about a patient or that leads to a patient being discovered, then you can end up with a criminal prosecution. So I can well imagine that people would be very careful about what they were going to do with this particular document.

  Q385  Dr Harris: I am still a little uncertain here about this publication issue. You spend a lot of time doing this work, you know that bits of the report can be blanked out, you can anonymise. I am keen to know whether you were concerned that once you had submitted your report it would never be published, and whether you were kept in touch with what the decision was on when it was going to be published.

  Professor Toft: In that case, yes. I did ring the department. I did ask them what was happening to the report. I was told that legal advice had been sought and I just kept on asking, "When is it going to be published?" What machinations went on in the department, I have no idea.

  Q386  Dr Harris: Why were there months of delay?

  Professor Toft: Dr Harris, I cannot speculate on that. There is no way I could possibly know.

  Q387  Dr Harris: Were there any recommendations in the report that you thought would be embarrassing to the Department of Health?

  Professor Toft: There is nothing in my report that I believe should be embarrassing to anybody. It is a statement of fact—at least, facts as I understand them.

  Q388  Dr Harris: In respect of this 85% compliance, that implies that there were 100 recommendations and 85 have been met. Or is it 17 out of 20?

  Professor Toft: I actually went through them yesterday. There are 103 recommendations in total. Some apply to the trust, some apply to the department, and quite a few apply to the Human Fertilisation Embryology Authority. I went through the ones for the authority yesterday and every one has been either engaged with (that is, implemented in full) or is an ongoing situation (that is to say, they are in the process of either having a committee or a working group to implement it). Some of my recommendations are not that easy to implement.

  Q389  Dr Harris: Do you think there needs to be a follow-up, an external outside follow-up of some kind, to ensure that all the recommendations that you have made—assuming that they are accepted—have been implemented, and that what the HFEA say—that they have a vested interest in it, given that they were criticised—is correct? Or do you think it is okay for us to take their assurances?

  Professor Toft: No, I would always argue that an external body should look at the recommendations of any inquiry and make sure they are implemented in full or at least an explanation is given as to why they have not been implemented in full.

  Q390  Dr Harris: Given the difficulties and question marks there were over the publication of your report, do you think there are other reports out there that have not been published following adverse incidents? Were you shown any of those as background to your work?

  Professor Toft: There have certainly been instances of adverse incidents of which the authority have notice, and those reports,[1] at least up until the point of my publication, I do not believe have been published. But, there again, with the situation that existed, where people were quite concerned about even people inside their own organisation knowing about adverse incidents, I could well imagine that there are incidents that have not been published.

  Q391  Dr Harris: Do you think it is healthy and good in terms of proper regulation that there should be these reports that have been made that are not published?

  Professor Toft: I think all things should be published. I think they should be transparent and open, and I think things can be suitably anonymised such that you can tell people, so that we can learn from these events. Having an adverse event is absolutely terrible in any situation. It tells you something about the world that you did not know, it is 100% learning, and, therefore, in as far as is humanly possible we should tell everybody as much as we can about these adverse events. It is 100%, pure learning.

  Q392  Dr Harris: How many of these unpublished reports on adverse events are there?

  Professor Toft: I could not say.

  Q393  Dr Harris: About.

  Professor Toft: In the research that was carried out by the authority on my behalf I think there were nine in total over the period between 1991 and when I did my report in 2002-03.

  Q394  Dr Harris: Given that you think, following the publication of your report, 85% of its recommendations have already been implemented, is it your view that, had some other of these reports been made public, some of the adverse events that followed and you had to investigate might have been avoided? Because you would have been report number 10, in theory, rather than the report that dealt with all these issues.

  Professor Toft: I take your point. In fact, the main event, the untoward event that I actually investigated, had never happened before. Certainly there was no indication in any of the events that I was later told about of a similar kind of event. The answer to your question, in that sense, is no. The event that occurred at Leeds and the second event that occurred at Leeds were unique to Leeds in the sense that somebody had taken the wrong sperm and fertilised the wrong eggs. As far as I know, that had never occurred before—or at least there is no documentary evidence that that had occurred before. The other events were to do with the implantation of embryos in the wrong person.

  Q395  Dr Harris: Have the HFEA changed their policy now, as far as you know? Are they going to publish more of the future reports of this nature? Has there been a change?

  Professor Toft: There certainly has been a change. I am given to understand that all the documentation is available to the public and so forth, and there is now an alert system that alerts all the clinics the moment they know of an event. They actually tell people that the event has occurred—suitably anonymised, of course. They are engaging in that now, which they did not do previously.

  Q396  Chairman: Topical around here this week has been the discussion of intelligence, how it is handled and so on, and the systems that there are. Would you like to say anything about the systems within the HFEA, or, indeed, whether problems are created by individuals and personalities and so on, or do you think there are some kind of cultural behavioural patterns in there that make it difficult to get the kind of support that you obviously wanted?

  Professor Toft: I think it is more to do with the culture than anything else. I think the culture was such that people over the period of time had become quite concerned about the nature of the regulations. In fact the Act itself, section 33, is quite draconian. If you make an inadvertent remark about anything that leads to a patient being discovered, then you can end up with a criminal prosecution. I think that over the years this has intensified. Of course I did mention in my report a thing called Group Think, which is to do with the way in which groups look at themselves. In fact it is a dysfunctional mindset. This is completely inadvertent; people do not engage in this deliberately, it kind of happens. It is a social-psychological problem.

  Q397  Chairman: We meet it quite a lot in our own organisation.

  Professor Toft: I am quite sure you do.

  Q398  Chairman: Do you think it has changed? Why has it changed? What evidence do you have that it has changed?

  Professor Toft: Personally I have no evidence that it has changed, I am just led to believe that things have been put in place which would help to prevent that from occurring.

  Q399  Chairman: It could still be a secret society.

  Professor Toft: Absolutely, Chairman.

1   Note by the witness: The word "reports" is used by me as a verb, not a noun. But the members of the Committee appear to understand what I have said as a noun from here on. There were no physical reports on the adverse incidents I refer to. But there were reports of adverse incidents to the HFEA. These reports (verb) were included in the HFEA minutes of Licence Committee meetings. And it was those reports to which I referred. Back

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