This article appears as part of the Inside the NHS newsletter.
A "critical incident" declared by NHS Grampian on November 28 sounded an early alarm bell for winter.
For around 48 hours, ambulances carrying patients whose conditions were "not immediately life-threatening" were diverted away from Aberdeen Royal Infirmary to alternative hospitals within the region, or to neighbouring boards.
Cancer treatment and diagnostic tests continued, but some planned operations and appointments were cancelled.
Speaking during a meeting of the board on December 12, chief executive Adam Coldwells said a high volume of delayed discharges combined with a "high number of admissions and the urgency of those" had triggered the crisis.
He added that things remain "very busy, very challenging".
Health Secretary Neil Gray wants to avoid any further critical incidents at emergency departments this winter, but a 'Strategic Risk Management Report' shared during the board meeting last Thursday shows Grampian remains at real risk of a repeat.
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The bed problem
The report warns that there is "an inability to achieve the required level of change and improvement to...provide a safe environment for patients and staff".
Many key strategic risks are "breaching acceptable risk tolerance levels, with no current ability to bring them back within agreed acceptable levels, primarily due to lack of resources".
The report adds that some of these are "predicted to worsen", concluding: "It has become evident that this situation cannot continue without further consideration as to how and if these concerns should be further addressed and potentially escalated".
NHS Grampian is far from unique in the challenges it is facing, but it is a bellwether partly because it has the lowest bed to population ratio in NHS Scotland: 1.4 bed per 1000 people, compared to a median nationally of 2.4/1000.
If that were matched by Grampian, it would equate into an extra 608 beds.
'Often unsafe'
A risk matrix at the end of the report rates four out of the ten risks as "very high" (five others are 'high', and one 'medium')
Demand for planned care - everything from hip replacements to cancer surgery - is "outstripping NHS Grampian’s current ability to effectively respond".
It cautions that this could result in a rise in avoidable patient harm, including death or disease becoming more complex and hard to treat.
NHS Grampian is also rated at "very high" risk of significant delays in the delivery of unscheduled care.
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Staffing levels are "often unsafe" with patients facing "excessive waits for emergency and acute treatment leading to routine and prolonged ambulance stacking".
Aberdeen Royal Infirmary has consistently struggled with some of the longest ambulance turnaround times in Scotland.
At the end of November, one in ten ambulances were waiting nearly five hours outside the ARI waiting to hand patients over to A&E.
'Functionally unsuitable'
Scottish Labour health spokeswoman, Jackie Baillie, described the report as "deeply concerning" for people living in Grampian, adding that it "points to serious concerns about the safety of patients" and provides a "snapshot into the gruelling experience faced by NHS staff".
Ageing buildings and equipment are also considered a "very high" risk.
According to the report, much of the board's estate is "functionally unsuitable" for its current purpose, and equipment - including digital infrastructure - is being "utilised on average well beyond recommended replacement timescales".
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There is a risk that this results in "reduced capacity for clinical care due to equipment failure or potential closure of buildings".
Finally, there is a very high risk that a lack of beds and staff shortages mean that it is "necessary to deviate from...expected patient care standards".
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