A healthcare watchdog has found "major deficiencies" in the handling of the death of a patient during surgery, following a damning report into failures by senior leadership at NHS Grampian.
Healthcare Improvement Scotland (HIS) revealed failures to learn from mistakes had caused repeated and avoidable harm to patients.
It also said it had lost confidence in NHS Grampian's management to deliver reliable and consistent information after it was ordered to halt all paediatric surgery at Dr Gray's Hospital in Elgin but continued to operate on some children until early August.
NHS Grampian chief executive Laura Skaife-Knight said the board accepted the findings and apologised to patients.
Serious weaknesses in all aspects of leadership and management of the medical workforce across NHS Grampian, including a lack of workforce plans, poor recruitment controls, and significant concerns in how doctors are managed
Concerns at Dr Gray's Hospital, including patient safety and the level of care given to patients, and the number of staff available to look after patients
A failure to fix problems on patient safety at NHS Grampian, including concerns of staff not working well together
A failure to deal with concerns about safety and quality of care at NHS Grampian's Board, including not ensuring services run as well as possible
Create a clear long-term plan for Dr Gray's Hospital, which states what services can be provided safely to patients and ensures there are enough staff in the hospital
Improve how NHS Grampian checks the quality of its services, including asking more questions when information is missing, looking at feedback from patients and staff, and showing how decisions are made
Create a plan for managing doctors, which includes how many are needed for each service and the skills needed for each job
Work with other organisations, including the Scottish government, to ensure problems are resolved and the situation improves for doctors and patients
Implement a better structure for making decisions and explaining how decisions are made, with the chief executive and chairperson of the board leading to sort the issues in the report
Health Secretary Angela Constance called the findings "extremely serious and deeply concerning" for patients, families, local communities and staff across Grampian.
She said: "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.
"Patient safety must come first, and people in Moray and across NHS Grampian must have confidence in the care they receive.
"This must be a turning point for NHS Grampian and the board must act with urgency in addressing the serious concerns."
Constance added that she expected to see "demonstratable improvements" before the end of the year and she would visit Grampian on Friday for its annual review.
The review was commissioned by NHS Grampian chief executive Laura Skaife-Knight.
She said: "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."
She said the report identified "significant shortcomings", including longstanding weaknesses in governance and oversight and the way services work together 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," Skaife-Knight said.
She added the board will consider the immediate actions that need taken and will approach the report with "openness and transparency".
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