An independent review of unplanned care at nine hospitals for the Health Service Executive has found that sometimes there was no clear understanding of who was providing the patients' care.
The Independent Review of Unplanned Care covered the years 2018-2019.
Due to emergency department pressures, it said there was widespread placing of patients in any bed, any time, anywhere, including mixed gender.
It said this did not create extra capacity, but led to safari rounds, increased length of stay and introduced harm by non-specialist care and increased staff absenteeism.
The review has recommended an end to the practice of trolleys being placed on wards as soon as the health system becomes stabilised.
None of the nine hospitals were found to operate a 24/7 model of care or appeared to provide safe and effective care.
The unpublished report was secured by the Irish Patients Association under the Freedom of Information Act.
While the HSE had decided not to publish the 2020 report, deeming it no longer relevant, the Department of Health agreed to release it taking a different view.
Steve McMahon of the Irish Patients Association, said it had taken 17 months to get the report and that it sheds light on why Ireland is seeing a number of systemic failures which are not purely accidental.
It examined nine hospitals which were under the greatest pressure during winter 2018/2019.
The hospitals selected were: Naas General, Tallaght University Hospital, Midland Regional Tullamore, Mater Misericordiae University Hospital Dublin, Cork University Hospital, University Hospital Limerick, University Hospital Waterford, St Vincent's University Hospital and Galway University Hospital.
It found that not only did the nine hospitals have the highest number of patients on trolleys during the year, they were also shown to have deteriorated over the previous five years, except for St Vincent's.
The average time patients spent in emergency departments before admission averaged from 10 hours 58 minutes at University Hospital Waterford, to 17 hours and 5 minutes in Galway University Hospital.
On its visit to University Hospital Waterford, the review team found that some patients were on trolleys for four to five nights on a hospital corridor.
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There were many variations in processes among the nine hospitals visited.
The review team found that all of the hospitals were challenged in terms of unscheduled care delivery, significantly greater than in many instances to hospitals in the UK, which "must inevitably put patients at risk and cause significant stress to staff".
It said the emergency departments in Tallaght and Limerick were new, while those in Waterford and Galway were old and barely fit for purpose.
Hospital staff did not always know who was in charge or if they were approachable or consistently visible.
There were questions about the adequacy of executive leadership and operational grip in many hospitals.
A lack of capacity and a shortage of staff and funding were consistent underlying themes.
The review team found that critical care areas were not kept clear to deal with emergencies, and often there were transfers of patients out to a corridor when a critically ill patient arrived.
"This is unsafe and is contrary to any acceptable model of emergency department practice," the review team said.
It found that emergency departments and wards appeared to work in their own silos and specialty teams offered little support outside of their own areas.
One of the recommendations from the hospital visits is to operate a model successfully deployed in Scotland, where there are early morning multi-disciplinary whole system teams huddled in hospitals, "to start the rhythm of the day and set the 'drumbeat' going".
It said these meetings should be executive-led at the start to ensure encouragement and that everyone is focused on safety, patient flow and over prediction for the day.
The review found that access to diagnostics in emergency departments is good for life threatening conditions, however for clinical decision making it was slower, particularly at weekends.
Early access to a senior decision maker was an issue at many hospital sites and needed to be addressed.
The review also found that the seven hospital groups' structure in Ireland has "an ambiguous role, provides limited support to hospitals and has no consistently explicit relationship to its relevant community services".
It has recommended a national management model that is less top down and more locally driven.
It has also said the full capacity protocol which hospitals implement if they are under severe pressure, should be an extraordinary measure and should not be accepted and normalised to manage ordinary variations in hospital pressures.
In opting not to publish the report in 2020, the HSE told the Department of Health that the benefit of releasing the report has significantly diminished in that its principle recommendation was to accelerate the implementation of the Capacity Review of 2018 and that many measures had been put in place since.
HSE Chief Operations Officer Anne O'Connor told the Department of Health that the review had been conducted at a particular point in time, during 2019 and "prior to the impact of the learning from winter 2018/2019".
She said the findings of the review were largely predictable and reflective of work already under way, including shifting demand to the community.
Ms O'Connor said that the relevance and usefulness of the findings of the review had been considered in the context of the accelerated improvements made to deal with Covid-19.
"Therefore, the HSE has taken a decision not to proceed to finalisation and publication of a report that no longer has relevance," she told the Department of Health.
However, the Department of Health said there were a number of issues of concern in the review for the department and it would not agree with the rationale not to publish.
It said there was no evidence that changes necessitated by Covid-19 had brought about the permanent long-term structural operational or organisational changes recommended in the independent review.
The independent review team was chaired by Professor Frank Keane, former president of the Royal College of Surgeons in Ireland. It included external clinical and management expertise from the NHS Scotland, the Scottish Government and the NHS England.
The team said that comparisons between hospitals should be regarded with some caution because hospitals vary enormously in size, catchment, capacity, activity, specialties and complexity.
In his executive summary, Prof Frank Keane said that hospital management teams must not enjoy having to face up to external scrutiny. He said the nine hospitals accepted the site visits with good grace, openness and a desire to learn.
The review team said it witnessed many incidences of outstanding practice, excellent patient care and was reassured by the many good things they saw happening.
In a statement, the HSE said the arrival of the Covid-19 pandemic in March 2020 required the HSE to respond to the extraordinary challenges posed, and in doing so resulted in the implementation of structures and initiatives to address many of the issues and recommendations that were identified in the draft report.
It said the review - undertaken in 2019 - has limited if any material benefit to be considered today as a basis for implementation, particularly given the action plans in place to address our current and future challenges.
