Critically ill hospital patients were put at risk by inadequate out-of-hours staffing levels, a report has found.
The Health Information and Quality Authority (Hiqa) said Mallow General Hospital in Co Cork did not have round-the-clock on-site expertise and facilities to safely manage patients with complex clinical needs.
Jon Billings, Hiqa's director of healthcare quality and safety, said services in Mallow were based on historic practices, with insufficient action at a local, regional or hospital group level to identify and anticipate risks to acutely ill patients.
He said: "The investigation found that the seniority of medical staff available on site outside core hours in Mallow General Hospital was not adequate for a hospital open to emergencies 24 hours a day.
"This has subsequently been addressed by the Health Service Executive (HSE).
"In short, the safety and quality of the service provided to patients was dependent on the willingness of local clinical staff at MGH, rather than a resilient and reliable system of care."
The authority highlighted a number of immediate patient safety concerns which came to its attention during the course of the investigation and requested the HSE take immediate steps.
The HSE has since introduced a mandatory policy for Cork University Hospital to accept critically ill patients from Mallow General Hospital.