Betsi Cadwaladr University Health Board, the largest health board in Wales covering the six counties of North Wales, recorded 11 never events in 2025/26 – a rise of six compared with the previous year. The Welsh health board with the second-highest total recorded seven never events.
What are never events?
Never events are serious, largely preventable patient safety incidents that should not occur if national safety guidance is adhered to. Examples include operating on the wrong part of the body, leaving surgical instruments inside a patient following an operation, or administering medication by the wrong route.
Health board's response
The figures are contained within the health board's annual report, which is due to be debated at its annual general meeting on Wednesday, July 29. 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."
It adds: "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." The report notes 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 further states 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."
Escalation and ministerial warning
Betsi Cadwaladr University Health Board has been in a heightened state of escalation for the past 11 years and at the highest level of escalation – level 5 – since February 2023. The Welsh Government took this course of action amid growing concerns over A&E performance, cancer waiting times, and finances. Wales' new health minister Mabon ap Gwynfor recently told the Senedd that the crisis-hit health board is being given a "final chance" to improve and stop "dragging the good name of the NHS down."
