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8 months ago
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A new mother was mistakenly fitted with a contraceptive coil in a surgery mix-up at an NHS hospital in Wales, it has been revealed.
The contraceptive blunder came just minutes after the woman had a baby by C-section in the hospital.
Labour-run NHS Wales described the coil mix-up at the Betsi Cadwaladr health board in North Wales as a 'never event'.
It was described as a 'serious, largely preventable patient safety incident that should not have occurred if preventative measures had been implemented'.
The health board outlined how a patient had a coil - an intrauterine device which prevents pregnancy - inserted after undergoing a Caesarean section.
It was described in the report as 'wrong procedure' planned for a different patient understood to have been admitted to Ysbyty Gwynedd hospital in Bangor. But a mistake had been made after the 'list order was changed due to the increase in category for this patient'.
A mother in a hospital in north Wales was mistakenly fitted with a contraceptive coil just minutes after giving birth [Stock picture]
A look at the birth control coil device which was wrongly fitted to the mother [Stock picture]
The coil blunder was one of three 'never events' for the north Wales health board in February alone.
Another patient 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.
Consequently, the north Wales health board was placed into special measures for the second time in February 2023 due to 'serious concerns about performance, leadership and culture'.
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', which are due to be discussed at a health board meeting.
The Welsh government's deputy chief medical officer, Chris Jones, said the mistakes may highlight 'potential weaknesses' in how an organisation manages fundamental safety processes.
The coil blunder was one of three 'never events' for the north Wales health board in February alone [Stock picture]
He said it was important they were identified and investigated fully.
Darren Millar, Welsh Conservative Shadow Minister for North Wales said: 'Never-events like these fall far below what is expected of our Welsh NHS and it will be a concern to people across North Wales that there are disproportionately more in the region than elsewhere in Wales.
'The NHS in North Wales is in special measures so Labour Ministers in Cardiff must share responsibility for these failures and act swiftly to address the shortcomings they expose.
'After almost nine years of Welsh Government intervention, it is clear that we urgently need an independent inquiry into the Betsi Cadwaladr University Health Board to ensure that lessons are learned and progress can finally be made.'
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