Systems at Jersey's General Hospital were a contributory factor in a woman's death, an independent report into the health service's care provision found.
Consultants Verita were commissioned to look into the surroundings of the death of Elizabeth Rourke, 49, after a routine operation in October 2006.
The report said the way the it was run created an unsafe patient environment and contributed to Mrs Rourke's death.
Verita gave the hospital 29 suggestions for improvement - eight of them urgent.
Relied on locums
Mrs Rourke underwent a routine gynaecological operation, hundreds of which are carried out in Jersey every year.
It was undertaken by Dr Deloroes Moyano, who was covering for a full-time member of staff.
At a trial in the Royal Court last year she was cleared of manslaughter and can still practice.
Verita said Dr Moyano's references were ambiguous and were not suitably checked and she had language difficulties.
The report stated the hospital relied too heavily on locum staff, the day surgery unit was too busy and the management of the hospital was not clear, was not working and senior staff did not provide sufficient leadership.