Serious patient safety and leadership failings found at NHS Grampian

An independent review has found very serious shortcomings in the leadership and oversight of patient safety at NHS Grampian.

Healthcare Improvement Scotland published its diagnostic review on Thursday 12th November.

It says the review was carried out in response to persistent, serious concerns about safety, quality, clinical governance and leadership.

NHS Grampian's chief executive, Laura Skaife-Knight, invited Healthcare Improvement Scotland to carry out the review.

The watchdog says many of the concerns had been raised with the health board before the review began.

They focused on Dr Gray's Hospital in Elgin and the wider clinical governance systems, which Healthcare Improvement Scotland describes as the critical systems that ensure patient safety.

The report contains a series of recommendations NHS Grampian must implement to address the failures identified.

Review of a patient's death during surgery

Healthcare Improvement Scotland says there was particular concern about learning from significant adverse events, and about patterns of repeated and avoidable harm.

It says there were major deficiencies in NHS Grampian's review of a patient's death during surgery.

According to the watchdog, this included inadequate analysis of the key factors contributing to the death and insufficient senior and executive oversight.

The report also identified governance concerns.

These include NHS Grampian's failure to recognise these shortcomings, providing incorrect information to Healthcare Improvement Scotland, and inconsistent accounts of executive medical involvement.

Healthcare Improvement Scotland says it has not yet received a satisfactory explanation from NHS Grampian about these concerns.

A separate review of the systems, governance and quality of NHS Grampian's significant adverse event reviews will now be carried out.

Wider weaknesses identified

The review identifies underlying systemic issues and recurring weaknesses regarding:

-- leadership and accountability

-- governance, assurance and board oversight

-- ability to effectively resolve problems and implement improvements

-- workforce

-- culture

-- service sustainability

-- candour and transparency

Simon Watson, Medical Director of Healthcare Improvement Scotland, said:

"We found weaknesses in clinical governance systems, leadership and organisational oversight. These are essential for an organisation to provide assurance to patients, staff and the public about the safety and quality of care they provide."

He also said:

"Despite these challenges, during the course of our work, we did see many hard working and committed front line staff providing good care. NHS Grampian must now implement the report's recommendations to ensure these staff deliver the safest, most effective and person-centred care for all their patients."

NHS Grampian response

Ms Skaife-Knight, who commissioned the review, said:

"As a Board we own and accept the findings, we apologise to our patients, families and communities for letting them down and we commit to putting things right."

She also said:

"That said, the report makes for very tough reading. It describes features of our leadership, governance and culture which are unacceptable and which cannot continue as I take this organisation forward."

The health board has made immediate changes to medical leadership, with an interim Medical Director starting on 16th November.

It has also set up a dedicated telephone line for anyone with specific concerns who wants to speak to the health board.

The number is 08085 202030, and it is open on weekdays from 8am to 6pm.

NHS Grampian says it will consider the immediate actions it needs to take at its public Board meeting on 3rd December 2026.

Other reports published

Separate Safe Delivery of Care inspection reports were also published on Thursday.

They cover maternity services at Aberdeen Maternity Hospital and Dr Gray's Hospital, and mental health and acute services at Dr Gray's Hospital.

Those inspections took place during the week beginning 27th April 2026.

Healthcare Improvement Scotland says the inspections and the review were carried out independently and should be considered as separate pieces of work.

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