Healthcare Improvement Scotland has published a damning independent review of NHS Grampian, finding serious weaknesses in leadership, clinical governance and patient safety across the health board. The watchdog said failures to learn from serious incidents had caused repeated and avoidable harm to patients.

The review found what it called “major deficiencies” in the handling of the death of a patient during surgery, and said the board had failed to fix known problems with patient safety, including staff not working well together.

Paediatric surgery continued after halt ordered

Inspectors said they had lost confidence in NHS Grampian’s management to deliver reliable and consistent information after the board was ordered to halt all paediatric surgery at Dr Gray’s Hospital in Elgin but continued to operate on some children until early August. Elective paediatric dental and ear, nose and throat surgery continued until 6 August, despite a suspension put in place on 9 July.

The review, commissioned by NHS Grampian chief executive Laura Skaife-Knight, also identified systemic problems at Aberdeen Royal Infirmary, including a lack of workforce plans and poor recruitment controls.

Six recommendations and 50 requirements

Healthcare Improvement Scotland made six recommendations, including a clear long-term plan for Dr Gray’s Hospital stating which services can be provided safely, a plan for managing doctors, and a better structure for decisions led by the chief executive and board chair. Separate inspection reports published alongside the review made 50 requirements to improve safety, after inspectors found ambulance handover waits of up to 14 hours and a high dependency unit relying on a locum consultant without round-the-clock medical cover.

Skaife-Knight said the board accepted the findings and apologised for letting patients down. Health Secretary Angela Constance called the findings “extremely serious and deeply concerning” and said she expected demonstrable improvements before the end of the year.