Mother killed by blood poisoning 'let down by out-of-hours GP cover'

An investigation into the sudden death of a 41-year-old womenhas branded the out-of-hours care she received as "not fit for purpose" and the investigators have told Gordon Brown he must end the chaos and confusion surrounding cover for GPs at nights and weekends.

Penny Campbell, a journalist and mother, died during the Easter weekend of 2005 after eight doctors working for Camidoc, a private company which covers GPs across a large area of north London, failed to spot symptoms of septicaemia. By the time Ms Campbell was admitted to hospital on Easter Monday, the blood poisoning she had contracted following treatment for haemorrhoids five days earlier had begun to overwhelm her system. She died from multiple organ failure 24 hours later.

An inquest into her death last year revealed that none of the doctors who treated her were able to access each other's notes, contributing to the seriousness of her symptoms being downplayed. She consulted eight Camidoc doctors over four days but was diagnosed with such varying conditions as flu, viral infection and food poisoning.

The inquest, and subsequent media coverage of the tragedy, forced the local Primary Care Trusts to call in independent investigators to establish what went wrong. Their report, due to be published today, concludes that "major system failure" was a direct factor leading to Ms Campbell's death and that Camidoc's system of clinical governance was "not fit for purpose".

It will say six GPs provided Ms Campbell with a "reasonable standard" of care but one, Dr Chuah, did not adequately explore her symptoms to see if she had an acute illness.

A transcript of their conversation the day before her death on Easter Tuesday shows that, when she checked with him that it was "not anything serious", he replied that if it was more serious she would be a lot more sick and "wouldn't be talking to me like this". The investigation found that the care offered by an eighth GP, Dr Bengi Beyzade, could not be adequately assessed in retrospect.

The absence of any clear system of accountability for dealing with major mishaps ensured that the Trusts only became aware of Ms Campbell's death when they were contacted by a solicitor acting for her partner of nearly 20 years, Angus MacKinnon, and their six-year-old son, Joseph.

Before 2004, GPs were responsible for organising out-of-hours services. But Primary Care Trusts took on that responsibility even though they had no previous experience in delivering out-of-hours care, and no pilot scheme had been organised anywhere. A senior member of the Government has since privately revealed that the proposed changes to the out-of-hours arrangements were never discussed in Cabinet.

Mr MacKinnon told The Independent yesterday: "It has always been clear to me that Camidoc's system at the time of Penny's death was completely shambolic. This report confirms that, but it also makes clear that this situation was the result of a huge policy change being implemented nationwide without any kind of trial or proper assessment of the risks involved."

Camidoc issued a statement saying: "The death of Penny Campbell was a terrible tragedy ... We accept and will deliver all of the recommendations, many of which we are already in the process of implementing."

A spokeswoman for Camidoc said that, in the case of the six doctors who provided reasonable care, they would be able to go back on the company's rota if they wished following a meeting with their PCT and the clinical governance team at Camidoc.

In the case of Dr Chuah, who was criticised, and Dr Beyzade, whose performance could not be assessed, they would undergo a much lengthier process if they wished to return to work, she said.