Media Release: NHS Grampian Responsive Diagnostic Review
Review finds serious clinical governance, leadership and patient safety issues at NHS Grampian.
Healthcare Improvement Scotland today (Thursday 12 November) 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 Responsive Diagnostic Review was undertaken in response to persistent, serious concerns about safety, quality, clinical governance and leadership. Healthcare Improvement Scotland 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 Healthcare Improvement Scotland prior to the review, focussed 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. There was particular concern relating to learning from significant adverse events and concerning patterns of repeated and avoidable harm.
Of particular concern were 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 Healthcare Improvement Scotland, and inconsistent accounts of executive medical involvement. Healthcare Improvement Scotland 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 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
The report contains a series of recommendations which NHS Grampian must implement to address the failures identified.
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 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 focussed 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.”
Medical Director, Healthcare Improvement Scotland
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, are also being published today. These inspections took place during the week beginning 27 April 2026. While published concurrently, the inspections and review were undertaken independently and should be considered as separate pieces of work.
Read the Aberdeen Maternity Hospital inspection report
Read the Dr Gray’s Hospital maternity inspection report
Read the Dr Gray’s Hospital mental health ward and acute services inspection report
Ends
Notes to editor
Simon Watson, Medical Director of Healthcare Improvement Scotland is available for interview today (Thursday 12 November) between 10am and 1pm. He will be available in-person at Healthcare Improvement Scotland’s Glasgow office: Delta House, 50 West Nile Street, G1 2NP. To book an interview slot, please email his.media@nhs.scot or call 07977 586 386
These reports are part of Healthcare Improvement Scotland’s programme of inspections and reviews.
Healthcare Improvement Scotland’s statutory role is to help improve the quality of health and care, provide information to the public about the quality of health and care services, monitor public involvement, and to evaluate and provide advice on the clinical and cost-effectiveness of medicines and health technologies.
Clinical governance is the ‘system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.’1. It is an essential part of any healthcare organisation’s work to keep patients safe.
1. Clinical Governance Standards; Healthcare Improvement Scotland (Feb 2026)
