Patients at King's College hospital, which is seeking trust status, were forced to wait in the accident and emergency department which was manned by junior medical staff with an excessive workload.
The poor conditions at the hospital in Camberwell, south London, were compounded by inadequate bed management policies that meant patients faced unacceptable delays before being admitted, according to the report commissioned by the Government.
The blame for the hospital's failings was laid firmly at the door of the management which, the report said, was ambivalent in its commitment to the hospital's role as a general hospital, a crucial part of which was the provision of a high-quality casualty department.
William Waldegrave, the former Secretary of State for Health, demanded the inquiry into the hospital last February following the deaths of two men.
Frederick Seymour, 84, was admitted last December suffering from heart disease, but went unnoticed by casualty staff for almost six hours. Once seen, he was placed on a hospital trolley where he died eight hours later.
Eleven days later, Jim Armfield, 75, who had been left waiting on a trolley, died from brain damage after falling from the makeshift bed.
The report, drawn up by a panel chaired by Professor Peter Higgins, vice-chairman of South East Thames Regional Health Authority, said the highest standards and procedures were necessary just to provide an adequate service, but there was 'little evidence' of this.
It said it was essential that the management commit itself to an 'efficient and humane accident and emergency service', while a high priority must be placed on rebuilding the department. Maximum waiting times should be set and monitored, it said. Patients should be interviewed by a doctor within an hour and admitted within four hours.
Camberwell Health Authority is spending pounds 3.5m on the redevelopment of the casualty department and taking on two extra consultants.
Sir Derek Boorman, chairman of the authority, said: 'Difficulty in admitting emergency patients to King's College hospital is a major concern . . . I therefore welcome the constructive recommendations.'
Virginia Bottomley, the Secretary of State for Health, said that the fabric of the hospital clearly needed to be improved, but was heartened that the authority had accepted the recommendations.
But Ian McCartney, Labour's health spokesman, said: 'The report is the tip of an iceberg of understaffing and under-resourcing of accident and emergency units throughout the NHS. The tragedy that took place at the hospital was an accident waiting to happen.'Reuse content