NHS Grampian has apologised to patients and families after an independent review found serious weaknesses in its leadership and patient safety systems, including repeated and avoidable harm.
Healthcare Improvement Scotland published its diagnostic review on 12 November. It examined how the health board identifies risks, responds to concerns and learns from serious incidents, with a particular focus on Dr Gray’s Hospital in Elgin and the wider systems supporting it.
The review found that the hospital was not sufficiently integrated into the board’s clinical and management structures. It concluded that the difficulties were not confined to Dr Gray’s, but reflected wider weaknesses requiring a response across NHS Grampian.
Chief executive Laura Skaife-Knight, who requested the review, said the board accepted its findings and apologised to patients, families and communities. She described delays in investigating incidents and putting learning into practice as particularly concerning.
Concerns about learning from harm
Clinical governance is the system through which health organisations oversee the quality and safety of care. It includes how problems are reported, assessed and acted upon, and how leaders check whether changes have made patients safer.
The review found a recurring pattern in which concerns prompted reviews, action plans or temporary workarounds without effectively resolving the underlying problems. It said there were major weaknesses in learning from significant adverse events and in escalating patient safety issues.
In one case, the regulator found major deficiencies in NHS Grampian’s investigation of a patient’s death during surgery. The diagnostic review said the investigation did not meaningfully examine the actions and clinical decisions of the operating surgeons. It also raised concerns about senior oversight and the accuracy of information supplied to the regulator.
The health board agreed to commission a new independent review of that case. The diagnostic report says the chief executive accepted responsibility for a letter containing incorrect assertions, apologised and took steps to correct the information. Healthcare Improvement Scotland says it will separately review the systems and quality of the board’s significant adverse event reviews.
The diagnostic assessment did not examine every service or aspect of NHS Grampian. Its evidence included organisational documents, previous inspections, adverse event reviews, interviews with leaders and discussions with frontline staff, alongside visits to Dr Gray’s and Aberdeen Royal Infirmary.
Recommendations for the board
The review made six recommendations. One calls for a realistic plan identifying which services can be provided safely and sustainably at Dr Gray’s, taking account of patient needs, staffing, links between services and the consequences for care elsewhere.
It also asks the board to strengthen its oversight of clinical quality and safety. Reviewers said board members had not always received enough information about significant risks and had not sufficiently challenged incomplete assurances. They recommended regular scrutiny of clinical outcomes, serious incidents, patient experience and vulnerable services.
Other recommendations cover medical workforce leadership, including recruitment, job planning and appraisal. The review also calls for simpler governance arrangements and for significant risks to be tracked from identification through to decisions, action and evidence of improvement.
NHS Grampian, the Scottish Government and relevant external organisations should agree how progress will be independently assessed, the review says. It calls for measurable outcomes rather than relying mainly on a list of completed actions.
Response and next steps
NHS Grampian said it had made changes to medical leadership and that an interim medical director would start on 16 November. Skaife-Knight said the board would consider immediate actions at its public meeting on 3 December and set out who was responsible for changes and how progress would be measured.
The board has established a telephone line for patients and families with specific concerns about their care. It said the line, on 08085 202030, is available on weekdays from 8am to 6pm.
Health Secretary Angela Constance said the findings were extremely serious and called for urgent action, including changes in medical leadership. She said she expected demonstrable improvements before the end of the year and was considering whether further escalation measures were needed.
Three separate inspection reports were published on the same day, covering maternity services at Dr Gray’s and Aberdeen Maternity Hospital, and acute and mental health services at Dr Gray’s. Those inspections took place in April and were independent of the diagnostic review.
Inspectors identified both concerns requiring improvement and examples of good practice. The regulator said its reviewers also saw committed frontline staff providing good care. The board’s stated task now is to turn its acceptance of the findings into changes that can be demonstrated and sustained.
