Baby Peter died from abuse despite 60 visits from authorities
Doctors at a clinic that failed to spot a broken back in Baby Peter two days before he died were under an "excessive workload", a report has said.
Peter Connelly, killed in 2007 in Haringey, north London, was seen at St Ann's Hospital two days before he died.
Dr Kim Holt, who warned about the way the clinic was run in 2006, said the 17-month-old baby could have been saved if managers had listened to her.
But the report found "genuine attempts" were made to address her concerns.
Dr Kim Holt, a senior consultant paediatrician, had warned the clinic's appointment system was "chaotic".
She was one of four who wrote a letter detailing problems at the hospital's clinic a year before the failed diagnosis.
They warned the clinic - run by Haringey Primary Care Trust and manned by Great Ormond Street Hospital doctors - was understaffed.
There had once been four doctors at the clinic, but two posts were cut before Baby Peter's death. Since the case, the number has risen to nine.
The independent report found "delays in seeing children must have the potential to affect patient safety".
It described Dr Holt as highly intelligent and committed, and added that communication between doctors and senior administrators needed to be managed "more effectively in the interests of patient care".
But it also said "genuine attempts" had been made to improve the situation after Dr Holt's letter.
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.
'Very hostile environment'
They also noted 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."
After the publication of the report, Dr Holt said said she and her colleagues' concerns were about the "quality of care" given to children at the clinic.
Tracey Connelly was jailed for her part in Baby Peter's death
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 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."
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 NHS Haringey to make sure recommendations are put in place.
"This report shows that Dr Holt's concerns were taken seriously."
The British Medical Association (BMA) is supporting Dr Holt's claim to be reinstated to her original post.
In a statement Great Ormond Street Hospital said: "The Trust welcomes the report, accepts its recommendations and now wants to move to try to resolve outstanding issues swiftly and amicably."
It added: "The Trust has apologised for its mistakes in the care of Baby Peter and has acted on all recommendations made.
Baby Peter died from abuse despite 60 visits from the authorities.
His mother Tracey Connelly, 28, her partner Steven Barker, 33, and Barker's brother Jason Owen, 37, were all jailed for their part in Peter's death.
Haringey Council's social services department was heavily criticised following the killing.