The Royal is a medical drama set in St Aidan's Royal Free Hospital in the sea-side town of Elsinby.
Mr Middleditch has come in to St Aidan's hospital, accompanied by his wife, for a routine operation. Noticing that Mrs Middleditch looks unwell, the hospital decides to give her a blood transfusion. Distracted by the attentions of a rich divorced playboy, who has promised to marry her, Susie Dixon administers the wrong blood, which later results in serious consequences for both her and the patient.
A new student nurse arrives at the Royal. Lizzie falls for a motorcycle stunt rider who is convinced he’s destined to live fast, die young. But Dr Ormerod comes up with a different diagnosis.
A patient with cancer dies unexpectedly after a visit from Dr Ormerod, and the grieving family point the finger at him. Dr Omerod is arrested on suspicion of murder – how will he prove his innocence? Dr Ralph Ellis holds a clinic at the local prison and is concerned about the mental health of one of his patients. When a full scale riot breaks out, Ralph’s trapped. Will he escape unscathed?
A secret from Jean’s past resurfaces when the wife of a former lover arrives at the Royal and accuses Jean of being up to her old tricks. When things take a shocking turn Jean is forced to reconsider her future as well as her past.
A family day out at the park ends in disaster for the Ormerods, Dr Ellis risks getting too involved with a patient in trouble and Lizzie attempts to improve her word power - with interesting results.
A girls’ trip out on board a pirate radio ship ends badly when they are embroiled in a siege. And Drs Ormerod and Weatherill are mystified when a girl guide leader recovers miraculously from a stroke.
There is a near crash on the road which involves a woman called Dolly and her daughter Alison and a rich aristocratic heir and his girlfriend. Ellis and Ormerod are called out to attend the scene of the accident. The car with Dolly and Alison in it ends up crashing into the lake to avoid the other car. With the car sinking Jack attempts to get them out. The other couple are taken to the hospital to be checked out where a water tank comes crashing through the ceiling and traps Tom the male driver. Suffering with a a ruptured spleen, Ormerod and Rose manage to free him and get him to theatre for surgery.
The hospital’s future is in doubt following DHA's decision not to sanction a financial package to repair the Casualty department. The hospital is only offered an authorised high interest loan, that doesn’t cover all the costs of the everything that needs to be done. The hospital's budget for the year ahead has also been cut so that the Royal will need to dip into the Middleditch trust fund to keep the hospital open. Jean ends up announcing that the only way forward is to consider a a complete closure of Casualty. Ralph ends up taking some secret action to rectify the situation but also ends up bringing up some difficult issues in his past. Carol and Ralph finally end up getting together.
A can of worms is opened when Gordon attends to a local family's problems, and when violence spills onto the Royal's wards he gets caught up in the crossfire. Meanwhile, baby Aisling's adoption is final. However, Sister Brigid is confused by her feelings.