An internal review at a leading children's hospital has found significant safety concerns in its theatre departments.
The report - released this afternoon by Alder Hey Children's NHS Foundation Trust after it was obtained by Channel 4 News - was presented to the trust board in December.
Written by director of nursing, Gill Core, who sits on the trust's board, it highlights safety issues and long-standing concerns among staff.
Under the heading "safety concerns", the report says " the high pressure, time constrained environment sustained and increasing, over a significant period of time, has resulted in work-rounds to speed up activity and avoid cancellations".
It said this has led to " shortcuts being made to safety processes that have created high risk activity", " limited reporting of incidents", " an almost complete lack of situational awareness" and a " belief that the senior management and the board are aware of the working conditions and condone it".
Furthermore, it said the environment had led to "fighting for position by specialist teams in order to capture any available slots".
The review comes more than a decade after the same trust was involved in a scandal over the retention of hearts and organs from hundreds of children.
The organs were stripped without permission from babies who died at the hospital between 1988 and 1996.
On the reporting of incidents - such as errors or near misses - staff had "almost completely abandoned" one system of reporting for several reasons, including "mistrust of how local management would use incidents".
The review, which makes a series of recommendations, said staff wanted to deliver the best possible service and highest standards of care to patients.
But it said the " greater the effort that has been made to increase theatre activity the greater the pressure experienced at all levels.
"Theatre staff are constantly changing duties, covering theatres that they have limited expertise in and frequently working beyond duty times, often in lengthy list overruns.
"Local theatre managers are occupied almost entirely with crisis management, re-arranging lists, covering sickness and dealing with demands from all directions.
"Other managers outside theatres are continually dealing with cancellations, explaining to parents, re-scheduling operations and trying to deal with the pressure from surgical teams to ensure theatre slots are provided and responding to senior managers regarding activity and cancelled operations performance.
"None of the staff, at any level, were able to describe how they were supported and many described a total inability to support anyone else due to the way they were working."
The report said some individuals "reported that the working environment is hostile and there are numerous examples of staff feeling pressurised to undertake activities that they do not believe are safe.
"The perception of mistrust of management and the board is such that there is a widespread feeling of hopelessness that change will ever be achieved."
The review also criticised the fact the environment "is not welcoming or child friendly" and "there is widespread evidence of multiple minor failures of equipment that have been ignored resulting in widespread apathy to pursue improvement".
The appearance of scrub suits is also reported as generally shabby, mismatched and not child friendly, reinforcing the feelings of lack of worth amongst staff.
There was also a "total absence of toys" reported.
In response to today's story, the trust said a report to the board in 2011 had highlighted concerns from a small group of staff relating to the working environment within the operating theatres.
It said "comprehensive measures were taken to improve this and since then the board and management team have continued to support staff working in this area".
Following the latest December review, the trust has implemented changes, including reorganising staffing and promoting improved use of the incident reporting system, it said.
Sir David Henshaw, chair of the trust, said the report was discussed at a public board meeting and was widely shared with theatre staff.
He added: "I would like to reassure all our families that concerns raised within this report relate to the working environment for staff.
"There is no evidence that patients have been harmed as a result of issues identified in the report and we are confident that we are providing a safe service for our children and young people.
"This report is the latest action by the board in an ongoing programme to support our theatre department.
"Theatres by nature are highly stressful, demanding working environments and we are aware that there have been difficulties within this department for some time.
"Over the past year, we have undertaken a range of measures to address concerns from staff and make improvements. The board and management team recognise that changes to the culture of the department take time and therefore have made a long-term commitment to supporting this team."
The regulator the Care Quality Commission (CQC) made an unannounced inspection in December after being directly approached by theatre staff.
A statement from the CQC said: "Concerns were raised with us and we carried out an inspection at Alder Hey Children's NHS Foundation Trust in December. The findings will be published soon."
Channel 4 reported that a 2010 internal psychological review of the department revealed high stress levels among staff, including concerns of self-harm and suicide.
Managers were described as "bullying...intimidating...coercive...aggressive...hostile...vindictive", it said.
Theatre staff were said to be exhausted from long hours, or physically and mentally unable to perform their duties confidently or competently.
"Several incidences were recounted where staff had fainted or had been otherwise incapacitated whilst in theatres," it said.