Review into NHS Grampian finds 'serious patient safety issues'

Key Points

Healthcare Improvement Scotland review finds ‘serious patient safety concerns’
Concerns over health board’s handling of patient’s death in surgery
Issues raised over governance and patterns of ‘repeated and avoidable harm’
HIS details ‘very serious shortcomings’ over leadership
Health board declared a critical incident in September

A Healthcare Improvement Scotland (HIS) review into NHS Grampian has identified “serious patient safety” concerns across the health board.

On Thursday, HIS published an independent diagnostic review of key services and systems at NHS Grampian in response to significant patient safety and quality-of-care issues.

The body was invited to undertake the review by the chief executive of NHS Grampian, Laura Skaife-Knight.

The concerns, many of which had been raised with NHS Grampian by HIS prior to the review, focused on Dr Gray’s Hospital and the connected wider organisational clinical governance systems – the critical systems that ensure patient safety.

The review found “very serious shortcomings with NHS Grampian’s leadership and oversight of clinical governance”.

It found particular concern relating to “learning from significant adverse events” and concerning patterns of “repeated and avoidable harm”.

HIS also identified major deficiencies in NHS Grampian’s review of a patient’s death during surgery.

This included “inadequate analysis of the key factors contributing to the death” and “insufficient senior and executive oversight”.

The report also identified governance concerns, including NHS Grampian’s “failure to recognise these shortcomings, providing incorrect information to HIS, and inconsistent accounts of executive medical involvement”.

HIS says it has not yet received a satisfactory explanation from NHS Grampian regarding these concerns.

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

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

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: “Our report identifies recurring patterns of harm and points to the need for stronger systems of learning and improvement to ensure that lessons are acted upon and similar incidents are prevented in the future.

“It provides a clear diagnosis of significant problems in key aspects of clinical governance. There are findings that will make for difficult reading for NHS Grampian’s leadership and will understandably raise concerns among patients, the public and staff.

“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.

“We were particularly concerned about problems in the way NHS Grampian investigates its most serious adverse events.  These concerns were mostly focused on the senior leadership of the organisation. The quality of NHS Grampian’s significant adverse event reviews are subject of further formal scrutiny by Healthcare Improvement Scotland.

“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.”

Separate Safe Delivery of Care inspection reports relating to maternity services at Aberdeen Maternity Hospital and Dr Gray’s Hospital, and mental health and acute services at Dr Gray’s Hospital, were also published on Thursday.

The health board declared a critical incident in September due to extreme pressure on the emergency departments at both Aberdeen Royal Infirmary and Dr Gray’s in Elgin.

Health board admits failures

NHS Grampian Chief Executive Laura Skaife-Knight, who commissioned the review, said: “The Healthcare Improvement Scotland Diagnostic Review, which has been published today, has identified serious failings within NHS Grampian. 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. 

“It must firstly be recognised that every day, thousands of patients receive excellent care from our dedicated staff and teams, as the three Safe Delivery of Care Healthcare Improvement Scotland reports – also published today – remind us.

“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. 

“We have 18,000 committed and dedicated staff who deserve to work in an environment where they feel supported and enabled by sound leadership, good governance and learning systems to deliver high-quality care.

“We have made some immediate changes to medical leadership with an interim medical director starting on November 16.

“I commissioned this diagnostic by Healthcare Improvement Scotland to get an independent and external assessment of Clinical Governance at NHS Grampian, including at Aberdeen Royal Infirmary and Dr Gray’s Hospital. 

“The review has identified significant shortcomings, including longstanding weaknesses in our Board governance and oversight, Clinical Governance and the way services work together in an integrated and supportive fashion across NHS Grampian. 

“Most concerning are the unacceptable delays in investigating and implementing learning from incidents involving patient care, which can prevent us from making the changes necessary to keep patients safe. 

“I know these findings will cause concern to our local community, particularly for patients and families who may have questions about their own care.

“This is why we’ve established a dedicated telephone line 08085 202030, available on weekdays 8am-6pm from today, for anyone who has specific concerns and wants to speak to us.

“Our focus is now about responding at pace to the feedback and making the improvements needed that are now long overdue. 

“We will approach our response to this report with openness and transparency by setting out clearly what needs to change, who is accountable for delivering that change and how progress will be measured so it is clear to everyone whether the changes we are making are delivering for patients and our communities. 

“Our job now is to work together across our organisation and use this report as a springboard for change and improvement, which is no less than our patients and staff deserve. 

“We will consider the immediate actions we need to take at our December 3, 2026 public Board meeting.”

Health secretary ‘considering further escalation’ on issue

Health Secretary Angela Constance said: “The findings of this report are extremely serious and will be deeply concerning for patients, families, local communities and staff across Grampian. It identifies significant failings in leadership, governance, accountability and organisational culture.

“I have written to the Chair and Chief Executive of NHS Grampian in relation to the report and was clear I expect decisive and urgent action. The report is particularly critical of medical leadership, of senior individuals and their role in the failures of clinical governance, decision-making and patient safety.

“Given the seriousness of these findings, I expect the Board to immediately make changes in medical leadership and to carry out any further necessary changes at a senior level to restore confidence in services.

“I understand that NHS Grampian have already made some changes to their medical leadership and an interim Medical Director has been appointed with effect from Monday, November 16.

“The Chief Executive of NHS Grampian, who took up post in September 2025, asked Healthcare Improvement Scotland to carry out this review in May of this year in response to growing concerns about the safety and quality of care, particularly at Dr Gray’s Hospital in Elgin. She was right to do this.

“Patient safety must come first, and people in Moray and across NHS Grampian must have confidence in the care they receive.

“Patients should continue to use their local services and NHS Grampian has established a dedicated helpline to ensure patients, families and local communities have a clear route to raise concerns, seek advice and access support.

“This report also acknowledges the professional and dedicated staff who continue to deliver compassionate care in challenging circumstances. This is echoed in three other HIS inspection reports published today in relation to NHS Grampian.

“This must be a turning point for NHS Grampian and the Board must act with urgency in addressing the serious concerns. A new Interim Chair of the Board was appointed in October and I expect to see demonstrable improvements before the end of the year. In the meantime, I am considering whether further escalation measures are required.

“I will visit Grampian tomorrow for its annual review and, contingent on the Parliamentary Bureau agreeing to its scheduling, I will set out the Scottish Government’s fuller response and steps being taken in a statement to the Scottish Parliament next week.”