North Wales health board reports 13 NHS 'Never Events' in a year

Betsi Cadwaladr University Health Board recorded 13 NHS 'Never Events' in the 12 months from August 2025 to July 2026, according to papers prepared for its September board meeting.

A Never Event is an official NHS category for a serious patient safety incident that should be preventable when existing national guidance or safety recommendations are followed. The classification does not by itself say what harm a patient suffered, and the paper does not name individual staff.

Five retained objects and four wrong-site events

The health board's table lists five incidents involving a retained foreign object after a procedure, four wrong-site surgery events, two involving a wrong implant or prosthesis, one wrong-route medication event and one misplaced nasogastric or orogastric tube.

The same paper describes four events in the latest reporting period: two retained objects, including a swab and a tampon after childbirth; a misplaced nasogastric tube where feed was administered before the position was correct; and a controlled drug given by the wrong route. The health board says all four investigations are ongoing, with further detail held in a confidential report.

Highest rate in the Welsh comparison

For the separate comparison period from 1 July 2025 to 30 June 2026, Betsi Cadwaladr recorded 12 events, or 1.73 per 100,000 population. That is the highest rate among the six Welsh health boards in the table. Cardiff and Vale recorded 1.54, while Swansea Bay recorded no events in that period.

The August performance summary says one further Never Event was reported during that month, taking the 2026/27 total to seven. It also records 5,084 open patient safety incidents, with 59.4% overdue. These wider incident figures are not all Never Events.

The published dates do not agree

There is an inconsistency in the board paper. Its narrative describes a rolling period from August 2025 to July 2026, but the category table labels the same total of 13 as running from June 2025 to July 2026. Cover Wales has used the 12-month period stated in the narrative and has not silently corrected the table.

The health board says a programme is under way to consolidate safety standards and audits. It says recurring themes show a need for stronger compliance, assurance and safety culture. The public paper does not give final causes or outcomes for the four latest events, so no finding of individual fault can be made from it.