Welsh Health Board records four serious ‘Never Events’ in three months

Richard Evans, Local democracy reporter

Betsi Cadwaladr University Health Board recorded four “never events” over a three month period, a report said.

A “never event” is a serious, preventable medical error that should “never” happen if the proper safety procedures are followed.

According to a health board report being discussed by board members at its March meeting tomorrow (Thursday, March 26), four “never events” were initially recorded in two months – with one incident later downgraded.

A new “never event” was then recorded in December 2025, making four in total.

The papers don’t elaborate on the errors specifically but refer to one incident as “wrong site surgery” and as a “chest drain”.

The report stated: “The Health Board reported four Never Events during October and November 2025, one of which has been downgraded as NHS Performance and Improvement (which) determined it did not meet the criteria for a Never Event.”

Under a section on “patient safety”, the same report later added: “The Health Board reported one Never Event in December 2025 relating to wrong site surgery (chest drain).”

The papers include an integrated quality report, giving an “overview of the Health Board’s current quality, safety, and patient experience position”, outlining key performance trends, risks, and progress.

An executive summary of that report, which highlighted the December 2025 Never Event, said: “While improvement is evident in several areas including complaints management, national clinical audit outcomes, and organisational learning, challenges remain in infection prevention, Health Inspectorate Wales (HIW) compliance, urgent and emergency care pressures, and systemic risks highlighted through mortality reviews and coronial findings.”

The revelation follows the Health Board remaining in special measures for a decade, with both Conwy and Denbighshire county councils declaring a health emergency.

Councillors are particularly concerned about the A&E department, corridor care, and waiting times, with Conwy County Council’s leader describing the NHS in North Wales as “third world”.

Betsi Cadwaladr University Health Board board members will meet at Llandudno’s Venue Cymru tomorrow (Thursday).