Gordon Brown, the Prime Minister-in-waiting, said today that the NHS had to "be there for people when they need it" after a damning report on the death of a woman who was forced to consult eight out-of-hours GPs in four days over an Easter weekend.

Penny Campbell, a 41-year-old journalist and mother, died in March 2005 from multiple organ failure. She had become infected with septicaemia during an operation for haemorrhoids but none of the doctors she spoke to or met diagnosed it.

A report by a panel of independent investigators published today found that the actions of at least one of the GPs, together with problems in how the out-of-hours service was run, meant that she was not offered appropriate care.

Camidoc, a private company contracted to provide out-of-hours cover, had no procedures to ensure that notes on patients were easily available to all GPs, so that each time she rang for help they treated her as a new patient. This was a "major system failure" and was a direct factor leading to Miss Campbell’s death, the report said.

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With the abandonment of 24-hour responsibility, being a GP became more of a job, less of a vocation. Penny Campbell was a victim of the change

Nigel Hawkes

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Ms Campbell's partner, Angus McKinnon, said today that he was convinced that a similar tragedy could happen again. "I’ve had dozens of people contact me, cases where people had really narrow escapes," he said.

Mr Brown was asked about the case at a South London school and said that the Health Service had to "do better".

"What I’ve been talking about is how we can extend the range of facilities for healthcare at the weekends and out of hours," he said. "So we need more access to doctors, we need walk-in centres, we need local healthcare centres to be more effective, we need NHS Direct to be working.

"And we need pharmacies, interestingly enough, to have more ability to, for example, do blood tests and some of the basic things where you can just walk in off the street and get some of the basic tests done. And we need prescriptions to be translated to people, directly to the chemist, in a way that you don’t have to queue up at the doctor’s for a repeat prescription.

"So in all these areas we need more access for patients. The health service has got to be there for people when they need it and we need to do better in the future."

But Mr Brown's intervention was scorned by the Tories. “It is odd that Gordon Brown should now realise that GP cover needs to be improved," said Andrew Lansley, the Shadow Health Secretary. “Just three years ago he allowed a new GP contract to go ahead, which doubled the costs of providing out-of-hours care and led to worsening services for patients.

Today’s report identified weaknesses in the arrangements for out-of-hours care. Responsibility for providing the care passed from individual GPs to Primary Care Trusts in 2004 when the new GPs' contract came in. The report criticises the speed at which the change was implemented, and urges the Department of Health to provide a clear definition of the role of out-of-hours care.

Ms Campbell, from Islington, North London, was diagnosed with various conditions by the GPs, including colic, flu and viral infections, an inquest heard last year.

The coroner ruled that the doctors contributed to Miss Campbell’s death because they failed to recognise the seriousness of her condition. All eight doctors voluntarily stepped down from out-of-hours care while the investigation into her death was carried out - although they continue to work as GPs.

Today’s report said that six GPs provided Miss Campbell with a "reasonable standard" of care but one, named as Dr Chuah, did not adequately explore her symptoms to see if she had an acute illness.

Dr Chuah failed to offer Miss Campbell a reasonable standard of care during an 11-minute call at 4.50am on Monday, March 28, the day before her death. A transcript of their conversation 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".

It adds: "Reviewing this transcript, it is apparent that Penny Campbell was articulate and coherent. In the course of the conversation she describes her symptoms quite clearly.

"It is also evident that Dr Chuah did not pick up the cues offered by her or further explore any of these symptoms to clearly and definitely exclude any serious pathology that could have accounted for these symptoms."

The investigation found that the care offered by an eighth GP, Dr Bengi Beyzade, could not be adequately assessed in retrospect. Camidoc has said the six cleared of wrongdoing will be able to work again for them following a review.

Dr Beyzade and Dr Chuah would have to go through a much more rigorous process involving a performance review with their PCT if they wished to return to work, it said.

Mr MacKinnon, 40, said the fact that the two doctors may be able to work again showed a "total lack of accountability" and was indicative of a wider problem regarding the work of doctors.

"To get justice where doctors have performed unprofessionally, to get justice for the victims of their incompetence, you have to sue them. That’s a broader problem within our health system," he said.

"Dr Chuah should be struck off."

Mr MacKinnon plans to write to the General Medical Council (GMC) about the conduct of four of the doctors. He is also pursuing civil action over the case.

Islington Primary Care Trust (PCT), which commissions Camidoc’s services, issued a statement today extending its sympathy to Ms Campbell's family and admitting failings in her care.

Today’s report says the system of "safety netting" - where Miss Campbell was told to call back if she did not recover - was "seriously flawed".

Each of her calls to doctors were treated as an individual "episode", with Miss Campbell having to recount her symptoms again and again. Although Camidoc had put in place methods to transfer to a computerised records system, it failed to address existing risks and take steps to overcome the problems.

The report says that Camidoc was unprepared for its shift to a major out-of-hours provider of care. It also criticises Camidoc’s lack of process for driving up standards, saying that the systems for ensuring clinical governance was in place were not fit for purpose.

The system of out-of-hours care in England has been much criticised, with a recent study from the Public Accounts Committee saying that the Government thoroughly mishandled its introduction. Prior to 2004, out-of-hours care was managed by GPs but this was handed over to PCTs as a result of the new GP contract.

Mr MacKinnon backed those criticisms today. "If Tesco can open till midnight every night, why can’t our GPs open till midnight every night?" he said

"The National Audit Office said last year that the reform of out-of-hours has been incredibly expensive - it’s massively over-budget - so if they had spent a little less money on doubling doctors’ wages they would be able to afford better night-time and weekend care."

Ms Campbell had a son, Joseph, who was 6 at the time of her death.

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