Health board in special measures logged most ‘never events’ in Wales

Richard Evans, Local Democracy Reporter

A Welsh health board recorded more “never events” than any other in the country last year, with the number of serious, preventable patient safety incidents rising sharply.

Betsi Cadwaladr University Health Board logged 11 new never events during 2025/26 – up from five the previous year and four more than the health board with the second-highest total.

The figures are contained in the health board’s annual report, which is due to be discussed at its annual general meeting on Wednesday, July 29.

Never events are serious, largely preventable patient safety incidents that should not happen if national safety guidance is followed.

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 report states: “The number of new never events is a key indicator of quality, safety, and governance within the health board. In 2025/26, eleven new never events were recorded, representing an increase of six never events compared with the previous year.

“The health board with the second highest reports a total at seven. This level of avoidable harm remains a serious concern and the health board is committed to ensuring ongoing improvements.

“There is a clear commitment to strengthening systems and learning to support a continued reduction in never events, with an ambition to achieve zero new never events throughout 2026/27 and beyond.”

The report concluded: “Each never event is treated as a serious patient safety incident and is subject to a robust investigation process in line with national guidance.

“Investigations focus on identifying system and process failures rather than individual blame, ensuring that meaningful learning can be achieved. Where required, immediate actions are taken to protect patient safety while investigations are completed.”

The report goes on to say that while never events and national reportable incidents “require further improvement, the strengthening of investigation, learning, and governance arrangements provide assurance that risks are being identified, managed and addressed consistently”.

Natasha Asghar MS, Shadow Minister for Health and Social Care, said: “The fact that supposedly ‘never events’ have more than doubled in the Betsi Cadwaladr University Health Board area is deeply alarming.

“These are serious incidents that should be preventable, so to see them increasing at a Health Board that has already spent 11 years under Welsh Government intervention is simply unacceptable.

“Patients and their families deserve to know that when they enter hospital, they will receive safe, high-quality care.

“These figures raise serious questions about whether the current intervention arrangements are delivering the improvements patients were promised.

“Ministers must explain why, after more than a decade of special measures and intervention, patient safety indicators are moving in the wrong direction.

“The Welsh Government must ensure the Health Board is held to account, that lessons are learned from every never event and that urgent action is taken to restore confidence in NHS services.”

The North Wales health board was put back in special measures in February 2023 – after previously being under targeted intervention from 2015 and 2020.

The Welsh Government took the action amidst concerns over A&E performance, cancer waiting times, and finances.

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