The number of “never events” has increased within Betsi Cadwaladr University Health Board over the past 12 months.

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

The Local Democracy Reporting Service reported in July that the North Wales health board had recorded 11 in a 12-month period – up five from the previous year.

At the time, this was four more than the Welsh health board with the second highest total.

But that figure has now risen to 13 within the last 12 months, recorded between August 2025 and July 2026.

Consequently, Betsi Cadwaladr remains the health board with the highest rate of never events per 100,000 of the population in Wales “presenting patient safety and reputational risks”.

Four never events related to “wrong site surgery”, and five were described as a “retained foreign object post procedure”.

The other incidents were recorded as “administration of medication by the wrong route”; “misplaced naso-or orogastric tubes”; and two “wrong implant/prosthesis” errors.

The report summarises: “Recurring themes include retained foreign objects, wrong-site procedures, incorrect implants, and failures associated with invasive procedures and medicines management.”

Betsi Cadwaladr University Health Board has largely remained in special measures for most of the last decade.

The report states: “Patient safety performance remains challenged, with 5,528 open incidents, over 62% of which are overdue (mainly within the moderate harm category), alongside 13 Never Events reported over the previous 12 months. Recurring themes relating to compliance with invasive procedure safety standards, medicines management, and clinical governance continue to require executive attention.

“Additional concerns have been identified regarding the reliability of resuscitation equipment checking processes and venous thromboembolism risk assessment compliance.

“The report also highlights growing concerns regarding endoscopy waiting list backlogs, surveillance delays and service fragility.”

The paper did acknowledge there is a serious problem, concluding: “Whilst robust action is being taken in response to each incident, including reinforcement of professional standards of behaviour where required, the recurring themes observed across recent Never Events indicate an ongoing need to strengthen compliance, assurance and safety culture across the organisation.”

The figures were released ahead of a Health Board meeting on Thursday, 24 September.

Betsi Cadwaladr University Health Board was contacted for comment.