Worrying gaps in medical cover, inadequate checks on deteriorating patients and nurse shortages are among problems identified by an official review into high patient death rates in NHS Lanarkshire.
The report also reveals emergency consultants believe they cannot continue to run A&E departments around the clock in Monklands, Hairmyres and Wishaw General hospitals.
Orthopaedics is also under the spotlight, with a review of the current spread of services one of the 21 recommendations for improvements.
The management of staff and patient safety initiatives in Lanarkshire was called into question by Health Secretary Alex Neil and NHS Scotland clinical director Jason Leitch following the publication of the report yesterday.
Dr Neil Dewhurst, president of the Royal College of Physicians of Edinburgh, said the findings made "depressing, but not surprising reading", adding: "Clinicians across Scotland will recognise the challenges facing colleagues in Lanarkshire."
The "rapid review" by Healthcare Improvement Scotland (HIS) was triggered this summer by mortality rates in the main Lanarkshire hospitals. The issue has now been narrowed to Monklands Hospital in Airdrie.
While no definite reason for the higher death rates was given, the review team said it was "concerned about the persistence of practices that represent an unacceptable risk to safe patient care".
Numerous examples of gaps in consultant cover were given.
The report said that during weekends at Monklands "it is not uncommon for patients on medical wards identified as at risk to be reviewed solely by a medical trainee in the early stages of training".
On general medical wards at Hairmyres Hospital, in East Kilbride, the review team heard that when consultants were on holiday "patients under their care on the medical wards are not routinely seen by another consultant." This meant a patient could go two weeks without seeing a senior doctor.
In addition specialists were limiting the number of patients they would see, regardless of how many required attention. Care of the elderly staff would only see eight patients per day from the acute medical receiving unit.
The report said that action to address staffing problems had been inadequate, noting: "A recurrent theme was that problems were regarded as insoluble and so sub-optimal, and variable care was tolerated."
Simon Barker, deputy chairman of the BMA's Scottish Consultants Committee, said the report provided a renewed opportunity for the Government and health boards to work together in "different ways to develop solutions which support the provision of sustainable healthcare services in Scotland". He added: "The report's description of the situation in Lanarkshire reflects the rising pressures on NHS services which have to deal with rising demand, the ageing population, falling budgets and a workforce that is trying its best to provide high-quality care."
Ian Ross, chief executive of NHS Lanarkshire, has accepted the report's recommendations and said he would go through the findings with clinical leaders. Patterns of medical cover during evenings and weekends have already been changed. He said: "We regret any occasion where patient care has fallen short of the high standards we strive for."
The Herald has been campaigning for a review of NHS and care capacity to prepare services to cope better with the growing elderly population.
Mr Neil said: "The issue here is not the overall number of consultants or overall number of nurses, it is about the management of the resources." Experts are being sent in to help NHS Lanarkshire make changes.
Labour MSP Neil Findlay has called for a debate in the Scottish Parliament to discuss the report.