Betsi Cadwaladr: North Wales wrong surgeries investigated

In addition to two "wrong site" surgeries, one patient was left with a medical swab inside their body

Three incidents which could have caused serious harm or death in north Wales hospitals are being investigated.

A Betsi Cadwaladr Health Board report has revealed that two of the cases were described as "wrong site surgery".

This term refers to a surgery performed on the wrong area of the patient, the wrong patient, or the wrong procedure.

The incidents, described as "never events", are said to be preventable as guidance is available and should have been implemented.

The third incident under investigation relates to a swab having been left inside a patient.

• Betsi decision 'premature', say opposition

• No improvement at health board, claim relatives

• Hospital's A&E report worst watchdog has seen

Matthew Joyes, acting associate director of quality for Betsi Cadwaladr, said in one wrong site incident the surgeon was "new to the health board".

"Initial inquiries suggest that the surgeon had not received training to enable him to view the images, and acted purely on the [incorrect] report, which contributed to the incident.

"A range of immediate safety measures have been implemented... including dual working of surgeons on call."

After the swab incident theatre teams have been reminded about the protocols regarding checking all swabs, sharps and other instruments at the end of procedures.

Staff shortages and poor communication

The report also reveals that during February and March there were 17 patient falls on health board sites resulting in severe or permanent harm.

"On review of initial learning from these incidents, there are several themes that can be identified that contribute to these falls," said Mr Joyes.

Those factors are said to be staff shortages, inadequate documentation and poor communication between staff or with families.

In the same two months the board received 364 complaints and 64 claims or potential claims for clinical negligence or personal injury.

"This is expected to rise significantly due to direct or indirect effects of Covid which has resulted in delays," says the report.