Review finds serious clinical governance, leadership and patient safety issues at NHS Grampian
We have published an independent diagnostic review of key services and systems at NHS Grampian. We carried out the review in response to significant patient safety and quality of care issues.
The Responsive Diagnostic Review was undertaken in response to persistent, serious concerns about:
- safety
- quality
- clinical governance
- leadership
The Chief Executive of NHS Grampian, Laura Skaife-Knight, invited us to carry out the review.
We raised many of the concerns with NHS Grampian prior to the review. 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 serious shortcomings with NHS Grampian’s leadership and oversight of clinical governance. There was particular concern about learning from serious adverse events and about patterns of repeated and avoidable harm.
The report contains a series of recommendations which NHS Grampian must implement to address the failures identified.
“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.
“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.”
Medical Director, Healthcare Improvement Scotland
The review is published alongside separate Safe Delivery of Care inspection reports on maternity services at Dr Gray’s Hospital and Aberdeen Maternity Hospital as well as a mental health and acute services inspection report at Dr Gray’s Hospital. These inspections and review were undertaken independently. They should be considered as separate pieces of work.
Further reading
- Report: NHS Grampian Responsive Diagnostic Review: November 2026
- Media release: Review finds serious clinical governance, leadership and patient safety issues at NHS Grampian
- Inspection report: Dr Gray’s Hospital, NHS Grampian – maternity safe delivery of care inspection report: November 2026
- Inspection report: Aberdeen Maternity Hospital, NHS Grampian – maternity safe delivery of care inspection report: November 2026
- Inspection report: Dr Gray’s Hospital, NHS Grampian – acute safe delivery of care inspection report: November 2026
- Media release: Inspection reports for Dr Gray’s Hospital and Aberdeen Maternity Hospital, NHS Grampian