Sick patients were put at risk by the state's failure to hold a Dublin hospital to account, the health watchdog has found.
No-one at Tallaght Hospital appeared to be accountable for those left lingering on trolleys in corridors for long periods, including one patient who waited six days for a hospital bed, said the Health Information and Quality Authority (Hiqa).
The probe into the emergency department (ED) in Tallaght was launched last summer after a 65-year-old man died on a trolley in a hospital corridor, where there was "insufficient privacy or dignity".
Health Minister James Reilly said it was completely unacceptable there was no clarity as to who was providing medical supervision and vowed no patient would be left lying on a trolley in any hospital by the end of the year.
"We must never forget that this report is first and foremost about patient safety and that it all began because of the death of a patient on a trolley in a corridor adjacent to the ED," said Mr Reilly.
Tracey Cooper, Hiqa chief executive, said the investigation uncovered a history of long-standing challenges in leadership, governance, performance and management at board and executive level in the hospital. The state and health chiefs also failed to hold the hospital effectively to account for the quality and safety of services or financial problems.
The investigation was launched when a coroner examining the death of Tom Walsh warned Tallaght Hospital sounded like a "very dangerous" place. He died a day after he arrived in ED in March 2011 in a "virtual ward" - a name given to corridors and alcoves where patients are left while awaiting a bed in a ward.
The corridor was a main thoroughfare for X-ray patients. The average wait for a patient to be seen and discharged from emergency care was six to seven hours, but some had a 61-hour wait, Hiqa said. And more than 80% of patients who needed admission were kept on a trolley in the nearby corridor for a further 13 hours until a ward bed was found.
Elsewhere the former board did not direct or govern the hospital, nor assure itself the hospital was providing safe care to patients, and serious shortcomings in financial affairs were uncovered and referred to the state spending watchdog, the Comptroller and Auditor General's Office.
Eilish Hardiman, chief executive of the new interim board at Tallaght Hospital, assured the public and the family of Mr Walsh the Hiqa report recommendations will be fully implemented. She added: "We firstly remember that a patient and a family were at the heart of this investigation and they are in our thoughts."