And the Scottish Government was accused of “dithering” over its response after it emerged ministerial officials were aware of the situation two years ago.
Staff experienced “fear, intimidation and inappropriate behaviour at work”, according to the review headed by John Sturrock QC.
Health secretary Jeane Freeman yesterday apologised and said other health boards should learn lessons.
Many people feel unable to speak out about the issue and believe there is no safe mechanism for them to do so.
The investigation, which was published yesterday, did not conclusively determine whether a “culture” of bullying exists at the board.
Ms Freeman told MSPs; “This extensive review has identified a number of significant cultural issues that have contributed to both actual and perceived behaviours in NHS Highland that have not always reflected those values.”
Mr Sturrock’s report did determine that senior officials in the Scottish Government were aware of the “dysfunctional situation” at the board and at senior leadership level for a “considerable period of time” prior to matters becoming more public in the autumn of 2017.
Tory MSP Edward Mountains said yesterday: “When four senior clinicians made allegations of bullying in September 2018, and I called in the same month for an independent inquiry from the First Minister, the government were still dithering.”
The report highlighted a tension for the Scottish Government between intervening and encouraging organisations and individuals to deal with issues themselves, indicating that government is often accused of over-involvement yet, when things go wrong, is held responsible.
It also found some individuals in senior management at the board are characterised as having adopted an “autocratic, intimidating, closed, suppressing, defensive and centralising style”. An absence of a vision with specific goals and timelines was highlighted as contributing to a “sense of lack of direction”.
In its recommendations, the report said a strategic vision is needed for boards with a programme of training for staff and managers.
It also called for effective facilities to be introduced to allow those wishing to speak out to do so.
Professor Boyd Robertson, interim chair of NHS Highland, said: “I undertake to do whatever I can to restore confidence where it may have been lost and to build upon the many examples of best practice which I see every day.”