Most nights Sean and I go to sleep knowing nothing about how you’re doing. Even though that is hard, we have kept our word. From the beginning, we told your parents that we would never intrude in their lives, or in yours. We thought that was the most generous way to move forward. We still stand by our promise to stay away unless invited, but want you to know that our absence says nothing about our love for you. Please never doubt that we care about you more than you could ever imagine.
Sometimes we think you are luckiest little boy in the whole world. You have two parents who treasure you, two sisters who adore you, and an extended family that, we imagine, are grateful for the gift of your life. And you have us too. Our door will always be open to you. If you ever need anything, as long as it doesn’t interfere with your family, please know that we are here with open arms and loving hearts.
I hope you had a wonderful first birthday. I hope someone baked you a cake that you dug your chubby little fingers into, and that you made a glorious mess. I hope when they sang to you, you smiled brightly when you realized they were singing for you. I hope you opened a few gifts, but enjoyed the wrapping and the boxes more than the contents. And, most importantly, I hope you felt loved.
Happy birthday; sweet dreams; and Godspeed, Little Man. We will love your forever!
Carolyn and Sean
AFTERWORD
CAROLYN AND I STRUGGLED over how to proceed legally with the clinic that made this error. We had never been involved in a lawsuit before and wanted to keep it that way. But this clinic and its personnel hurt us in many ways. We also felt we had a duty to protect other patients of this or other clinics from a similar fate. If we avoided a suit and agreed not to disclose the name of the clinic or how the mistake happened, we would not be comfortable that we did everything to make sure this mistake would not be repeated at this facility or any other facility.
The legal process we pursued was a facilitation in which both parties engage each other through a third party to try to reach an agreement that prevents a lawsuit from being filed. We entered this process open-minded, but understood resolution might not come through facilitation. At our first facilitation in October, just weeks after delivery of Logan, we walked into the law firm of the facilitator and past the conference room where our fertility doctor sat. As we passed by the large windows of that conference room, Carolyn grabbed my hand and squeezed it tightly. I knew she would rather be anywhere else than in that place at that time. By the time we arrived at our conference room, she seemed ready to escape through the back door. The last time Carolyn and the doctor were this close he was performing the embryo transfer.
We spent five hours in the first facilitation, followed by two additional longer sessions in 2010. I think part of the strategy of these terribly long days is to motivate you to reach an agreement so that you can avoid ever having to go back. Each session produced a broad range of emotions from anger to sadness and, due to the absurdity of some of the legal arguments, even some humor. Following the third session some breakthroughs occurred and an agreement in principle was reached in May 2010. However, the process was far from over as it took well into November 2010 for the agreement to be signed by all parties.
As part of the settlement we agreed not to identify the clinic and the clinic agreed to pay us financial damages. The clinic also agreed to provide a full description of the mistake and how it was discovered as well as provide us documentation that it has implemented a revised protocol in its lab that would ensure that this mistake was never repeated. Written into the agreement was a clause that allowed Carolyn and I to release a summary of the medical mistake and revised protocol information to the public. We felt an obligation to share this with the IVF community including clinics, industry associations, current patients, and future patients.
Through this process Carolyn and I had to maintain a balance between protecting the public and having a level of compassion for the employees of the clinic. The professionals involved had spent their careers building an excellent reputation and we believed that they should continue to help couples have children.
The settlement did not feel like a victory to us. If anything, the process and ultimate resolution was sad and stressful and I am sure it was even more so for the clinic and our doctor. A settlement in a situation like this never gets you back to where you were before the mistake. We incurred massive costs that went well beyond expenses, stress that frequently took us to our knees, and lost time we will never get back with those around us, especially our children.
Carolyn and I will be tithing funds from the settlement and the proceeds from the book into a community foundation under the name of the Carolyn and Sean Savage Family. With our guidance, each year Drew and Ryan (and eventually Mary Kate) will help select worthy charitable causes for the foundation to support. When the appropriate day arrives, Logan will be invited to help us direct funds from the foundation.
HOW THE MISTAKE HAPPENED
For nearly eighteen months, Carolyn and I lived knowing another couple’s embryos were transferred to Carolyn on February 6, 2009, but not knowing how the mistake was made or how it was discovered. Who was responsible? What went wrong? How did it get discovered? As part of a legal settlement in May 2010, the clinic’s lawyers provided an explanation. A synopsis of that explanation follows:
Upon initiating our frozen embryo transfer, an employee of the clinic completed a thaw order document that listed the name of our fertility doctor, our names, Carolyn’s social security number, Carolyn’s date of birth, my date of birth, and our phone number. Once the physician’s staff forwarded the thaw order to the lab where the embryos were stored, the lab confirmed that it had received the order.
With the order, an employee in the lab then printed labels containing all of the identifying information found on the thaw order. Every document pertaining to our frozen embryo transfer carried a label. *Important: These labels identified Carolyn’s year of birth incorrectly.
The lab technician placed these labels on four pages called the patient jacket, an 11x17 sheet of paper folded in half. This jacket holds all the documents and laboratory notes on the development of the embryos along with the thaw order sheet, the receipt confirmation sheet and any leftover patient identification labels.
On February 2, 2009, five days before our transfer, the embryologist used our identifying information on the thaw order in our patient jacket to pull our Embryo Information Sheet, a document that indicates the precise location of the cryopreservation tank, the canister and the straws that house our embryos. The clinic keeps their Embryo Information Sheets on every patient in a large binder in the lab organized alphabetically under the mother’s name.
This embryologist looked at the thaw order document in our patient jacket, flipped to the “S” section of his binder, and incorrectly pulled Shannon Savage’s Embryo Information Sheet instead of Carolyn Savage’s (Shannon used her maiden name at the time of their original IVF procedure). Using location information from Shannon Savage’s Embryo Information Sheet, he pulled Shannon Savage-Morell/ Paul Morell’s embryos from the cryopreservation tank. Our embryos remained in cryopreservation. The Embryo Information Sheet, the only paperwork that documents that the embryos the embryologist pulled did not belong to Carolyn and me, was placed in the back of the patient jacket.
From that moment on, Shannon and Paul’s embryos were associated with Carolyn and my paperwork. Since the lab associated their embryos with our paperwork, the name Savage was written on the Petri dish and the canister storing the embryos. Our patient jacket was stored right next to the canister holding the embryos. If anyone had checked the Embryo Information Sheet in our patient jacket, they would have found Shannon and Paul’s Embryo Information Sheet.
For the five days that the embryos thawed and grew in the lab, the embryologist checked the embryos/labels against the identifying information in the patient jacket. However, the embryos/labels were not checked against the Embryo Information Sheet inside the patient jacket.
On the transfer day February 6, 2009 the embryologist walked into the procedure room where Carolyn was lying awaiting the transfer. He confirmed Carolyn’s identity against the patient jacket he held in his hands.
The doctor verbally conlrmed that three embryos would be transferred. Then the embryologist delivered three of Paul and Shannon’s embryos labeled with our names to the doctor. He also delivered the patient jacket to our doctor at this time.
The doctor, trusting these were our embryos, did not cross check the Embryo Information Sheet held in the patient jacket and immediately transferred three of Paul and Shannon’s embryos to Carolyn.
An error by the embryologist of the lab initiated the wrong embryos being pulled and then an insufficient protocol failed to catch the original error in the subsequent five days the embryos grew in the lab before transfer. The initial error by the embryologist in pulling the wrong Embryo Information Sheet was the key misstep, but the fact is this piece of paper was inside a thin file next to the embryos in every step of the five day process, including the procedure room where the embryo transfer took place. In our opinion, those responsible for the mistaken transfer include everyone involved in the process from the moment the wrong Embryo Information Sheet was pulled February 2nd through the transfer February 6th. Any member of the clinic involved with establishing and monitoring the safety protocols for the clinic is also responsible. The clinic’s protocol was not sufficient and this is evidenced by the fact that the clinic changed its safety protocol on February 16, 2009, the day after the error was discovered.
The change was made too late for us, but fortunately not too late for future patients. Under the clinic’s new protocol, in the event that two patients have the same last name, the staff affixes a bright orange sticker to the data sheets in the binder to alert personnel. The clinic created a “Patient Verification Form” that has multiple confirmations of patient identification information. Labels on the canes and straws containing the embryos now have five identifiers. The new protocol requires that the staff check all five identifiers before proceeding to the next step. The physician him/herself double checks all identifying information before completing the transfer. Initial documents are cross-checked, not just recently produced documents.
When our clinic discovered this weakness in their protocol, they conducted a review of patient records to be certain that they had made no other mistakes. By doing this, they confirmed that this was the only time that they had transferred the wrong embryos. Thankfully no one else they treated received our fate.
HOW WAS THE MISTAKE DISCOVERED?
Our settlement agreement also required that the clinic describe how the error was discovered. Upon reading the description of the discovery my stomach sank and I had to read it again to make sure I was not mistaken. The explanation is outlined below.
On Sunday, February 15, 2009 a clinic employee was doing data entry work into a computer regarding all transfers from the previous two weeks when a discrepancy in Carolyn’s year of birth was discovered. Her label wrongly indicated that Carolyn was born in 1967 when her correct year of birth is 1969 and this caused the employee some confusion. To confirm the correct date of birth he decided to dig deeper and he paged through the patient jacket and found Shannon Savage’s Embryo Information Sheet in the back of Carolyn’s patient jacket.
The employee immediately called the embryologist who came to the lab and soon discovered the error. The embryologist contacted Shannon’s physician who in turn called our doctor.
Our doctor then waited until Carolyn’s positive pregnancy test the next day to inform us of the error.
The birth year being incorrect on the labels and Carolyn’s wristband had nothing to do with Paul and Shannon’s embryos being transferred to Carolyn. The birth year being incorrect was an independent error. Thus, it took a second mistake to discover the first mistake. Had Carolyn’s year of birth been noted correctly, the wrong embryos would still have been transferred, but the error would not have been discovered on February 15th. The error probably would have gone undetected until Paul and Shannon would have decided to go through with a frozen embryo transfer. At that time the embryologist would have gone to pull their Embryo Information Sheet from the binder and it would have been missing. Likely, he’d then go to the cryopreservation tank and would have discovered that Paul and Shannon’s embryos were missing. We do not know when this discovery would have been made.
I have been told the likelihood of the wrong embryos being transferred is one in three million. What are the chances that an independent error would have been made in conjunction with the same patient that would lead back to the original mistake? This is truly inconceivable.
Carolyn and I struggled with how or if to forgive while we dealt with the impact of the clinic’s actions. Kevin Anderson helped us by introducing the idea of intolerant forgiveness: the ability to forgive the person who committed the error, but not the actual mistake. But while Carolyn was still pregnant, we couldn’t embrace the idea as there was so much else on our minds. After Logan’s birth and our movement into the next phase of acceptance of what had just happened to us, we focused more attention on how we would deal with the clinic on multiple fronts, including how or if we could ever forgive.
As the legal facilitation process played out, we learned through the mediator that our doctor was visibly distraught. His attorney communicated his deep sorrow for everything surrounding the mistake and the impact it had on our lives. His ongoing struggle with guilt and regret and the sincerity with which he communicated those feelings moved us. Yet our feelings about him were deeply conflicted. All along we knew his expertise and skill brought us Mary Kate when, for more than a decade, everyone else in his field had failed. We felt compassion for his suffering and thankfulness for his expertise with Mary Kate, but we also felt continued anger at him for introducing such a cross to bear in our lives.
We believe in having compassion for those who hurt us. Frequently, we fall short, but we needed to help him and all of those in the clinic to move on from this incident. Just as we had written a letter to him on February 18th, we felt compelled to do the same in January 2011.
Dear Doctor,
On numerous occasions we received your messages of deep sorrow and remorse that we understand is shared by several individuals in the clinic. We know these messages are heartfelt and they motivated us to send you this note.
We forgive you and everyone involved in the clinic who is seeking forgiveness. We cannot excuse the act, but we do have compassion for everyone who has to live with this mistake every day. Please release yourself of any guilt and move on with your life. You have much good to do with your career and your family.
Sincerely,
Carolyn and Sean Savage
INCONCEIVABLE CHOICES
THERE ARE TIMES in everyone’s lives when they have to make difficult choices. Whether by a fateful accident, or circumstances self-created or brought about by another, somehow you are faced with a choice that you will need to live with for the rest of your life. These types of choices can be wide ranging: from fertility problems, aging parents, medical crises, career crises, marital issues, to parenting challenges. These are moments when the world seems askew. When facing these inconceivable choices, you need as much help and support as you can find. Support can come from your faith, or from those you know and trust, but it can also come from those you have yet to meet.
For us, the defining moment on this journey came on February 16, 2009 when we learned about this inconceivable medical mistake and made the choice not to terminate the pregnancy, nor to fight for custody of Logan after he was born. In the aftermath of those choices, we leaned on our faith, counselors, family, and friends for support. Help also came in a nontraditional manner: Carolyn found a group of women online who had faced infertility problems. Her “Reliable Girls” were spread around the United States and Canada but their support was as constant and immediate as if they were living around the corner. We
also tapped into other online resources to answer our many questions. Our experiences inspired us to build an online community specifically designed to support people who are facing difficult choices. That community is growing right now at inconceivablechoices.com.
We welcome you to this community if you are facing a difficult choice or if you want to provide input and support to other members. We have also invited experts in specific disciplines including counselors, psychologists, psychiatrists, spiritual leaders, and professors to provide advice on issues the community is facing. The various points of view both from these experts as well as other members will benefit members of the community while they are deciding their course of action, as well as support and compassion in the aftermath of their choices.
Our vision for this community is that it will inspire regular people like us to do the right thing, which in turn will benefit our world. We will be at inconceivablechoices.com trying to help and seeking support as well. Please join us.
ACKNOWLEDGMENTS
THIS BOOK WOULD not have been possible without the amazing work of our collaborating writer, Danelle Morton. Danelle, thank you for your countless hours of shaping, editing, and writing! Your insights and keen eye for how to arrange a well-told story have been priceless, and your patience and grace through the challenging moments did not go unnoticed. We are especially grateful for the way you motivated us to write through the most painful of memories. You said we’d be better for it. You were right. We cannot wait to see what you do next, as it seems that everything you touch turns to gold!
We owe a lifetime of gratitude to our literary agent, Linda Loewenthal of the David Black Agency. At a time when we were getting many calls, we had the good fortune of being referred to David, who listened, understood, and knew you’d be the best match for us. We are well aware that you went above and beyond for us throughout the entire process and were always our number one advocate. We have respect for your professionalism and expertise and admire your personal ethic. You are a blessing in our lives.
Inconceivable Page 27