Wrong patient fitted with coil after Caesarean

A new mum was confused for another patient and mistakenly fitted with a contraceptive coil after a C-section.

Another patient in north Wales almost had the wrong toe removed during surgery to amputate two others.

A third incident happened when a patient, unable to swallow oral medication, had it crushed, mixed with water and administered with a syringe.

These so-called “never events” happened at hospitals in the Betsi Cadwaladr health board area in February.

While details of hospitals and patients involved have not been released, these incidents will be discussed at a health board meeting later.

NHS Wales describes a never event as a “serious, largely preventable patient safety incident” that should not have occurred if preventative measures had been implemented.

In the latest available annual figures, there were 37 never events at hospitals in Wales between April 2021 and March 2022.

Betsi Cadwaldr health board, which covers all of north Wales, accounted for 12 of the 37 never events, while 10 happened in Aneurin Bevan health board’s hospitals in south-east Wales.

There were none in the Powys or Hywel Dda health board areas in mid and west Wales.

In a report into the three incidents in February, Betsi Cadwaladr health board outlined how a patient had a coil – an intrauterine device which prevents pregnancy – inserted after undergoing a Caesarean section.

Described in the report as “wrong procedure”, it had been planned for a different patient but a mistake had been made after the “list order was changed due to the increase in category for this patient”.

Another incident, described in the report as “wrong site surgery”, described a patient who was due to have their second and third toes amputated.

However, an incision was made in their fourth toe by accident.

Luckily, the error was spotted and the correct toes were amputated.In the third never event, described as “wrong route”, the report details the case of a patient who was unable to swallow oral medication.

To administer it, a member of staff crushed it, mixed it with water and “inadvertently” gave it intravenously, according to the report.

The Welsh government’s deputy chief medical officer, Chris Jones, said never events may highlight “potential weaknesses” in how an organisation manages fundamental safety processes.

He said it was important they were identified and investigated fully.

The three never events that happened will be discussed at a Betsi Cadwaladr health board meeting at Venue Cymru, Llandudno, Conwy, on Thursday.

The health board has been approached for comment.