'Never events' at Wales' largest health board more than double in a year
BBCThe number of "never events" at the largest health board in Wales more than doubled in a year, according to its latest report.
Never events are serious, largely preventable patient safety incidents that should not happen if national safety guidance is followed.
Betsi Cadwaladr University Health Board (BCUHB) logged 11 never events in 2025-26, increasing by six compared with the previous year.
The health board with the second-highest total recorded seven incidents.
The report said the level of "avoidable harm" remained a "serious concern" for the health board, which is "committed to ensuring ongoing improvements".
Examples of never events can include operating on the wrong part of the body, leaving surgical instruments inside a patient after an operation or administering medication by the wrong route.
The figures from the health board's annual report are due to be discussed at its annual general meeting on Wednesday.
The report said investigations focused on identifying system and process failures rather than individual blame, so "meaningful learning" can be achieved.
"Where required, immediate actions are taken to protect patient safety while investigations are completed," the report added.
It said the board had a "clear commitment to strengthening systems and learning to support a continued reduction in never events" and hopes to achieve zero never events in 2026-27 and future years.
The health board was put into special measures in February 2023 after previously being under targeted intervention from 2015 to 2020.
The Welsh government took the action over concerns over A&E performance, cancer waiting times, and finances.
Tehmeena Ajmal, chief operating officer at Betsi Cadwaladr University Health Board, apologised to the patients and families who have suffered "never events".
"We absolutely recognise there will be public concern around last year's increase. I can assure you that I and my colleagues share that concern," she said.
"So, it is vital we learn from each and every event, embedding the learning and taking action to ensure they do not reoccur. Our executive team has already overseen detailed analyses of these events and will oversee improvements."
