North Wales Health Board Reports Ten 'Never Events', Including Wrong Bowel Removal for Cancer Patient
A recent report to Betsi Cadwaladr University Health Board has detailed ten 'never events' occurring within the North Wales NHS over the past twelve months. These critical errors included five 'wrong site' procedures, two instances of incorrect implants, two cases of retained surgical objects, and one incident of medication administered via the incorrect route.
One egregious case involved a cancer patient at Bangor's Ysbyty Gwynedd, where a surgeon removed the wrong segment of bowel. The report stated that the surgeon, relying on a 'very visible tattoo or marking' as an indicator, operated on the incorrect area, necessitating further investigations and subsequent surgery for the patient.
Another incident at Wrexham's Maelor Hospital saw a patient, referred via an Urgent Suspected Cancer pathway, receive cryotherapy on the wrong anatomical site during a dermatology clinic visit. This error was identified by the patient after the procedure, leading to corrective surgery on the same day. Investigations into this particular incident are ongoing, according to the report set for consideration at an upcoming meeting.
