Coroner blames out-of-hours care for death of misdiagnosed woman

A coroner said he wants the Health Secretary, Patricia Hewitt, to conduct a national review of the system for out-of-hours care following an inquest into the death of a woman who was misdiagnosed by eight doctors whom she consulted over the course of a bank holiday weekend.

Penny Campbell, 41, was suffering from septicaemia caused by a bacterial infection picked up during a routine procedure for haemorrhoid pain. But, even as the infection was starting to poison her blood system leading eventually to multiple organ failure, doctors were dismissing the journalist's symptoms as flu, a virus, food poisoning and colic.

The coroner who conducted the inquest ruled yesterday that the failure to recognise her symptoms by a string of doctors, all working for her local London out-of-hours service, contributed to her death.

The coroner, Andrew Reid, took the unusual step of saying he would report his findings to the Health Secretary in order to highlight shortcomings in the system. Coroners have the power to make such reports in cases where they believe action may be needed to prevent similar fatalities.

It emerged during the inquest that although over the four days of her illness Ms Campbell repeatedly consulted Camidoc, the out-of-hours GP co-operative that served Ms Campbell's area, reporting fever, abdominal pains, and a rash on her body, doctors did not check their predecessor's notes on her condition.

Medical notes were not computerised at the time of her illness, the inquest heard. And notes from home visits were filled in by the drivers who chauffeured the doctors, sometimes not until the end of their shifts.

The coroner said that, while he believed there had not been a gross lack of medical attention, crucial clinical information had been missing and "was not always readily available to the last doctor in the chain".

Ms Campbell was an associate editor on Time magazine. Her partner, Angus MacKinnon, welcomed the coroner's decision to refer the issues raised in the inquest to government level.