Staff had problems getting a resuscitation trolley to patients at a major emergency department because of overcrowding, a regulator has revealed.
Trolleys at the Royal Victoria Hospital in west Belfast were packed close together and the area was crowded with patients on chairs as well as relatives.
The former chief medical officer of England, Sir Liam Donaldson, is to advise Northern Ireland's health minister on improvements to the service after the serious concerns were highlighted.
A regulator's report said: "Limited access space for staff, lack of cubicles and high footfall has resulted in patients being nursed on trolleys and chairs throughout the emergency department.
"Patients are placed beside the central work station and ambulance triage, in front of the resuscitation area, in the side corridor at X-ray, and in the back corridor along the short stay unit."
A major incident was declared at the Royal earlier this year due to a large backlog of patients in the emergency department. Another unit at a nearby hospital was closed in 2011.
While health spending in Northern Ireland has been protected from cuts, Stormont health minister Edwin Poots wants to reduce the number of people visiting emergency departments when other services like out-of-hours doctors could accommodate them.
In January Mr Poots asked the Regulation and Quality Improvement Authority (RQIA) to carry out an urgent inspection of the emergency department and acute medical unit at the Royal.
An inspection was carried out over four days at the start of February.
It found significant challenges for employees in ensuring the smooth flow of patients across the hospital as well as staff shortages in critical areas.
It said: "Many patients were being cared for outside the locations that were designed to deliver the care and treatment they required.
"This was having a considerable impact on the experience of patients and was creating risks in ensuring patient safety.
"The effective operation of critical departments, in particular the emergency department, was being put at risk by the need to care for patients, who should have been transferred to other more appropriate environments and care teams.
"Staff in affected departments were working hard to maintain patient safety, but were finding this stressful and difficult to maintain for a prolonged period."
There was evidence of increased staff sickness and difficulties were experienced in recruiting and retaining staff in key posts.
The report added: "Within the emergency department, the physical access to patients in an emergency is difficult when being cared for in the focused assessment area.
"Trolleys are closely packed together. The area can also be crowded, with patients on chairs, and accompanying relatives. Staff reported that they have problems getting the resuscitation trolley to patients in these circumstances."
Inspectors found significant challenges for medics in dealing with peaks of demand, meeting targets like those for trolley waits and the transfer of patients across hospitals to specialist wards.
The report added: "The operation of the emergency department was also being put at risk by the need to care for patients who were waiting for admission to a ward within the hospital."
Mr Poots said he wanted to take action to correct what went wrong.
He added: "I was deeply upset to hear of suggestions that dignity is not always afforded to those who die in our emergency departments. This cannot continue and must change.
"I was angry that staff did not feel supported in delivering the care they wish to and I was particularly angry at the suggestion that targets should come before patients.
"This is unacceptable and I cannot and will not tolerate it."
Sir Liam will be commissioned to advise him on improvements on governance arrangements across the health service, the minister said.
He will also investigate whether current arrangements support a culture of openness, learning and making amends.
Janice Smyth, director of the Royal College of Nursing (RCN) in Northern Ireland, said the issues raised reflected a wider problem across the health service.
She said: "We believe that questions must be asked as to how we reached this stage. The whole system needs to learn from this, particularly around listening to and acting upon the concerns of frontline staff.
"We must tackle the culture within the HSC that creates these problems. It is the responsibility of those charged with the governance of the HSC, including trust boards, to take ownership of and accountability for these issues."