A fertility clinic has been ordered to apologise after it destroyed a woman's embryos without her permission.
The Deputy Health and Disability Commissioner (HDC) Rose Wall released a report into the incident on Wednesday which found Fertility Associates had breached the Code of Health and Disability Services Consumers' Rights.
The report said the woman, known as Mrs A, underwent IVF in 2008 and had three remaining embryos which were frozen in storage.
In October 2017, she and her husband were informed that the storage of their embryos was due to expire and they filled out a form selecting to collect them from the clinic, intending to bring them to her mother's grave.
"After very careful consideration of the options, including investigating embryo donation, we decided that we would discard our embryos at the 10-year mark, July 2018," she told the HDC.
"We completed the appropriate document in October 2017. The document gave consent for the embryos to be discarded, and we ticked the box saying we would like to collect the embryos, rather than have them discarded at the facility."
However, after the embryos were removed from storage, there was no evidence the fertility clinic ever contacted the woman for collection.
"If [a] patient request[s] their embryos to be returned or collected, once ready for collection, we call the patient to inform them to collect from the clinic or advise them that we have couriered their embryos," an embryologist from the clinic told the HDC.
"Normally I would document this on their file however on this occasion it appears that I did not document making the call."
The clinic then disposed of the embryos by incineration.
Fertility Associates told HDC that it was sorry that the situation occurred and said they had not had a similar case over the past 10 years.
"We believe we communicated clearly with [Mrs A and her husband] regarding the process of discard and the intent to discard and had clear direction from them that they wished their embryos to be removed from storage. We are truly sorry that they were not then made aware when that happened and were therefore not given the opportunity to collect their embryos.
"We have taken their concerns very seriously, as has been shown by the update of our forms. I would like to again sincerely apologise to [Mrs A and her husband] regarding this failure of communication and for the distress this matter has caused them."
Deputy Commissioner Wall said in the report that a better system was needed to ensure the "important step" of contacting patients wasn't missed again.
"The return of her embryos was clearly of significant importance to [the woman], and her wishes should have been respected," Wall said.
"This did not occur, and was an undeniable omission by the fertility clinic."
She recommended Fertility Associates provide further training for staff and write an apology to the woman.