A senior doctor who claimed Baby P could have been saved if concerns about a hospital had been listened to was "taken seriously", according to a report published today.
The youngster was seen at St Ann's Hospital in Tottenham, north London just two days before he died.
Dr Kim Holt, a consultant paediatrician, said she and three colleagues wrote an open letter detailing problems at the hospital's child development clinic - which was run by Haringey council with doctors employed by Great Ormond Street Hospital Trust - in 2006.
They claimed the clinic was understaffed and had a "chaotic" appointment system which was a risk to patients.
She said the death of Baby P, now known as Peter Connolly, could have been prevented if the concerns were addressed.
Baby Peter died from a catalogue of more than 50 injuries inflicted by his mother, her boyfriend and his brother in August 2007.
He was seen by a locum doctor at St Ann's before he died, but the medic astonishingly failed to notice the child had a broken back.
The report published by NHS London found Dr Holt was taken seriously by the trust and that its management made "genuine attempts" to address her concerns.
But it concludes communication between doctors and management needs to be managed "more effectively in the interests of patient care."
The report's authors found no evidence to support the allegation Dr Holt was bullied or discriminated against for raising her concerns.
Professor Trish Morris-Thompson, chief nurse at NHS London, said: "We accept in full the findings of this independent report, and we are working with both NHS Haringey and Great Ormond Street to make sure that the recommendations in this, and all previous investigations following the tragic death of Baby Peter, are put in place.
"We must make sure that every lesson is learned to safeguard children in our care. This report shows that Dr Holt's concerns were taken seriously by both the Trust and PCT, and also NHS London. The report finds no evidence that Dr Holt was bullied or to suggest that managers interfered in clinical decision making, but we accept that more could have been done to support both clinical and managerial staff in delivering the services required.
"The findings of this report have been shared with Dr Holt and we support the report's recommendation that Great Ormond Street seek further mediation to make sure Dr Holt can return to work as quickly as possible after a period of absence. Any further actions that need to be carried out will be closely monitored by NHS London."
The report's authors described the workload of consultants at the clinic between 2006 and May 2008 as "excessive" and said the consequences of cutting a consultant post "were not adequately considered" by management.
They also noted "the lack of notes on consultation and delays in seeing children must as a matter of common sense in our view have the potential to affect patient safety".
The report's authors also heard complaints of a "very hostile environment" at the clinic with poor communication between staff and managers.
But they concluded: "We do not consider, however, that this descended into a bullying regime."
Dr Holt said her and her colleagues' concerns were about the "quality of care" given to children at the clinic.
She said: "We followed internal Trust channels, only going outside when they had been exhausted. I hope now that everyone will be able to learn from this report and move on. I want to contribute positively to improving services for children in Haringey, which was always my objective.
"I also hope that in future it will be far easier for NHS staff, in Haringey or anywhere, to speak out in the interests of their patients, particularly those who have no voice of their own."
The British Medical Association (BMA) wants Dr Holt to be reinstated at the clinic.
Dr Mark Porter, chairman of its Consultants Committee, said: "This has been a sad and extremely difficult case for everyone involved, and one that shows how hard it can be for doctors to raise their concerns.
"The NHS and all its constituent organisations must get better at recognising the invaluable service to patients performed by those who raise well-founded concerns about safety and quality."