Overcrowding at one of Scotland's busiest emergency departments led to "serious concerns" about patient safety and their dignity, according to a report.

Patients spent up to 25 hours on trolleys in corridors waiting for treatment and in some cases were left lying on "urine-soaked sheets" and in another on a "blood-stained pillow for several hours" at the Royal Infirmary of Edinburgh.

Healthcare Improvement Scotland (HIS) inspectors also raised concerns over fire safety in the overcrowded A&E after two visits to the hospital - the first of which was carried out between February 20 to 22 and a further unannounced follow-up in March.

The watchdog found "multiple systemic failures" in a report published on Thursday but NHS Lothian said a major improvement drive was already underway.

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The health board added that the hospital was had just endured its busiest winter on record ahead of the inspections.

At the time of the inspection, the emergency department was on some days operating at over three times its capacity.

The report described this as unsafe and a "fire safety risk" with the evacuation plan in place at the time not reflecting the "significant" impact of overcrowding. 

As well as patients being transferred from the A&E to other care areas being found "soaked in urine", staff highlighted that "fundamental care needs were not being met due to pressures in the emergency department". 

The watchdog emphasised further patient dignity concerns after many receiving care on trolleys did not have blankets to cover them. 

The report adds: "Another example was 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 witnessing this also appeared distressed."

However, when inspectors highlighted the situation to nursing staff they were told the patient had received pain relief but no further action was taken to support the dignity of those receiving care.

While the majority of those receiving care had blankets upon the repeat visit, the watchdog adds that "concerns about patient dignity and experience of care remained".

During both visits, inspectors needed to request assistance from staff to prevent patients falling out of trolleys.

In one case an inspector needed to intervene to stop someone falling from a trolley as they tried to push themselves over the side rails to get to the toilet.

Medication errors were also recorded during the inspections, including patients receiving the wrong medication or seeing delays in receiving it at all.

The report adds: "During both inspection visits within the emergency department, we observed a number of intravenous infusions had run dry and remained connected to these patients.

"We also observed intravenous infusions being connected without staff carrying out hand hygiene, or cleaning the cannula port prior to connection of an intravenous giving set."

Senior A&E managers told inspectors this was a result of "pressures" within the department. 

The watchdog's concerns were escalated to NHS Lothian in a letter of non-compliance after not enough improvements were made by the time of the second visit. 

HIS chief inspector Donna Maclean said: "At the time of the inspection, Royal Infirmary of Edinburgh, like much of NHS Scotland, was experiencing a significant range of pressures including increased admissions in the emergency department and admission units and reduced staff availability.

"The hospital was operating at over 100% capacity.

“During the inspection, our inspectors raised a number of serious concerns about the safe delivery of care in the hospital’s emergency department.

"We raised concerns about patient safety, care and dignity, leadership, the coordination of care and staff wellbeing. As a result, we wrote to NHS Lothian to formally escalate our concerns."

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Most of the inspectors concerns were in regard to the overcrowded A&E, but  inspectors observed respectful and caring interactions between staff and patients in the majority of ward areas.

Ms Maclean added: “Despite these concerns, our inspectors observed respectful and caring interactions between staff and patients in the majority of ward areas. 

"Patients and relatives we spoke with in all care areas, including the emergency department, said they had received kind and compassionate care from staff, which was also witnessed by inspectors during their visits. Nursing staff told us that they felt well supported by senior nursing leadership.

“In order to prioritise the requirements from this inspection, an action plan has been developed by NHS Lothian and will seek assurance on progress with planned improvement actions.”

The health board said the inspections were carried out at the same time as teams had begun major redesign work to improve patient safety and flow. 

Alison Macdonald, nurse director for NHS Lothian, said: “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.

“We had already begun our own improvement work when the inspectors carried out their first visit. When they returned for their follow up, it was clear to see that improvements had already been made, but more was required.

“It’s important to bear in mind that the inspection covered 13 wards, intensive care and the Emergency Department, and inspectors highlighted a number of areas of good practice relating to compassionate care, visible and supportive leadership, and a strong focus on patient care needs which we were encouraged to read.

“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."

Among other changes plans are underway to cater the layout of the emergency department to increase capacity and create a larger discharge area.