Betsi Cadwaladr University Health Board recorded the highest number of “never events” in Wales last year, according to its latest annual report.

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 health board logged 11 new never events during 2025/26 – an increase of six on the previous year.

The Welsh health board with the second-highest total recorded seven.

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

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”.

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.