An Edinburgh hospital emergency department was forced to operate at more than 300 per cent of its capacity this winter, a report has revealed.
Healthcare Improvement Scotland (HIS) has written to NHS Lothian to escalate its "serious concerns about patient safety within the emergency department" at the Royal Infirmary of Edinburgh.
Inspectors who visited the hospital in February said staff had reported a range of incidents "affecting both patient and staff safety", including cases of violence and aggression towards staff, patients receiving the wrong medication, and instances where patients had fallen off trolleys.
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The report also told how a patient was "observed in a corridor area on urine-soaked sheets, with another patient on a blood-stained pillow for several hours before this was changed".
HIS told how staff had "reported fundamental patient care needs were not met and had raised concern about the impact of overcrowding on patient dignity".
Its report said: "Inspectors observed that the emergency department was overcrowded, at times with no space for staff to move in any direction due to the number of patients being cared for in corridors and around the nursing stations."
As a result, the inspectors said they were "not assured of fire safety within the emergency department" - saying this issue had been "escalated to NHS Lothian along with other concerns".
It comes after the inspection team visited Edinburgh Royal Infirmary over three days in February, at a time when the NHS was "experiencing a significant range of pressures".
At one point in the visit, inspectors found 110 patients in the emergency department - which has 35 cubicles and four resuscitation bays.
They said "patients were being cared for on trolleys in corridor areas or at the side of the nursing stations".
The report went on to note: "Evidence provided by NHS Lothian demonstrated that within the week prior to the first onsite inspection, the department was at times operating at over 300 percent capacity."
Describing the emergency department as being "extremely busy", the report went on to raise concerns about patient dignity.
During their visits inspectors saw patients being cared for on trolleys beside nursing stations, and "many patients on these trolleys did not have blankets to cover them".
There was also "a very visibly distressed patient who had removed their outer clothes leaving only their underwear in place whilst being cared for on a trolley beside the nursing station".
Other patients in the area who saw this "also appeared distressed", the report said, adding that when inspectors highlighted the situation to nursing staff they were told the patient had been given pain relief, but the report said "no further action was taken to support patient dignity".
While the emergency department had "more patients than available space", the report said a third of staff on duty during inspection visits were supplementary staff - such as staff working additional hours after a shift has ended or agency workers.
HIS said "this had a negative impact on the safe delivery of care" as pressures within the department meant senior staff did not have time to monitor the quality of care being delivered.
The report said "leadership and oversight of care within the emergency department was not effective", while medical staff were "openly critical of senior leaders in discussions with inspectors".
Medical staff also "expressed frustration with the overcrowding and that risks to patients and staff as a result were not being addressed", the report added.
HIS has written to NHS Lothian chief executive Calum Campbell, seeking "written assurance on the immediate actions" the health board will take to address its concerns.
Alison Macdonald, nurse director at NHS Lothian, said: "There has been unprecedented pressure on our healthcare systems, which has been relentless in recent times, as the inspection team was able to experience first-hand."
But she said NHS Lothian is now "focused on our improvement and safety action plans".
Ms Macdonald added: "We accept and acknowledge the findings of the HIS report and we sincerely apologise to patients for longer than usual waiting times in the ED and a poorer experience of care."
She said NHS Lothian had "already begun our own improvement work when the inspectors carried out their first visit" - adding that when they came back for a follow-up visit, "it was clear to see that improvements had already been made".
But she added: "We recognise too that there is much work to be done. Safety and wellbeing of patients and staff are our main priorities, and I want to reassure them that we are doing everything possible to improve."
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