An unconscious patient undergoing surgery at the University Hospital of Wales fell from an operating table in an incident that could have resulted in serious injury, according to sources at the crisis-hit Cardiff hospital.
It is the latest in a series of alarming incidents at the hospital’s operating theatres, where earlier this year a surgical swab was accidentally left at the back of a patient’s throat for more than 24 hours following surgery. Last year the department was at the centre of a damning internal report that found illegal drug use and other potential crimes had been tolerated by management.
Now sources have claimed a patient fell from an operating table on June 5 while they were under general anaesthetic for the removal of their gallbladder. It is alleged they had not been securely strapped to the table.
We understand the patient was not injured in the fall and was informed of what happened after waking up following surgery. The hospital launched a full review of the incident.
We were told the fall was about four feet and the patient made contact with the floor but not at full impact. The health board has not disputed that there was contact with the floor.
It is alleged that at the time of the drop there were laparoscopic ports inside the patient – metallic devices that are inserted into the abdominal wall to allow for surgical access. “That’s dangerous,” said one source. “Imagine the infection risk from having been on an operating floor with open wounds.”
They claimed: “The theatre manager came running out of the theatre shouting ‘a patient’s fallen on the floor’. They had to get extra staff to help put them back on the table. They then carried on with surgery.”
The health board denied the incident was a “never event” – defined by the NHS as a “profound failure in care” that can have life-changing consequences.
Its executive nurse director Jason Roberts said: “This incident is not classified as a never event, as it does not meet the established criteria for that categorisation… When any patient safety incident occurs, regardless of classification, we have clear and robust processes in place to ensure it is recognised, reported, reviewed and learned from.”
Sources claimed it was unprecedented for a patient at the University Hospital of Wales to be dropped during surgery, though there have been falls at other hospitals. In 2021 the BBC reported a patient in England had died after being dropped on the floor during surgery on her hip.
And the previous year a patient at an unnamed hospital received compensation having suffered an injury when she “slipped down towards the floor” during an operation.
One source close to the Cardiff incident claimed: “I’ve never seen this before. It’s unbelievable. It’s part of the checklist before an operation: ‘Is the patient strapped to the table? Are the straps tight enough?’
“Worst case scenario, the patient hits their head on the floor and dies. If there is a suturing needle inside then the medics might not be able to find it, or it could puncture something.
“They were very lucky this didn’t happen at a crucial part of the operation, for example clipping a vein or artery, or even if the patient was bleeding inside. Can you imagine trying to control a bleed and a patient falls off a table? You’re not going to control that bleed.”
Last year a report into the hospital’s operating theatres concluded the department did not have “an open and transparent safety culture where people all feel able to speak up freely”. It also found an “atmosphere of fear” was “destroying the bonds which allow people to work effectively together”.
One source claimed after the dropped patient incident: “New staff aren’t given the support and time needed to train. Lots of experienced staff have left because of the toxic culture.
“Staff have been told to keep it quiet and not say anything. This is the typical response from the health board. After all the recent scandals they’ve been making serious threats to everyone against speaking to the press, but they’re failing to address the actual issues that put people at risk.”
One scandal after another
In the last year WalesOnline has revealed a stunning series of failings at the health board, including allegations of unauthorised visitors being invited in to watch operations and an employee avoiding suspension despite being arrested on suspicion of rape.
Since last year the health board has been in what the Welsh Government calls ‘level four’ escalation. This is one step short of special measures.
Last month an inquest found a patient, Donald Gough, had died after being wrongly injected with insulin following multiple failings and system breakdown.
Gareth Idris Johnson, a 41-year-old dad, lost his life after the hospital’s maintenance problems led to him being moved to a different unit following an operation. A coroner warned of more deaths without urgent action.
Whistleblowers have frequently spoken to us about the horrendous conditions at the pigeon-infested site. We recently published a letter from almost 300 doctors accusing the health board of inaction on the hospital’s problems, with staff morale at an “all-time low”. Its dilapidated condition is understood to have been a factor in Wales losing a vital £8m cancer facility.
There has been a series of scathing internal reports, including one from 2024 which concluded there had been “systemic failure at all levels of the organisation for over 10 years”.
One former employee of the hospital, Cherrill Atkinson, told us she witnessed a colleague snorting a white powder on the premises. She reported the matter to HR but was told they were already aware he had “confidential” issues. He later received a promotion.
We revealed one employee kept his job despite a disciplinary investigation upholding an allegation he had exposed his private parts to a young female colleague.
‘All policies and processes were followed’
Responding to the allegations over a patient being dropped, Mr Roberts told us he could not give specific details for confidentiality reasons. He did say: “I would like to provide assurance that all policies and processes were followed.”
Speaking about the health board’s process for patient safety incidents, Mr Roberts added: “The incident is formally recorded through our reporting systems and a thorough review is undertaken to understand what happened and identify any learning.
“This includes consideration of equipment, procedures, human factors and environmental factors, with any necessary actions implemented to reduce the risk of recurrence.
“We are committed to openness and transparency with patients and families and to fostering a culture where colleagues feel safe and supported to raise concerns through established channels. Patient safety remains our highest priority and we are committed to learning from incidents and continuously improving the quality and safety of the care we provide.”
If you know of a story we should be investigating, you can email us at conor.gogarty@walesonline.co.uk
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