A review into the NHS was ordered after the inquiry suggested that badly trained doctors were being employed to look after patients at nights and weekends.
Foreign doctors hired by care firms may not be able to speak good English and staff may be overworked as adequate checks are not being carried out, the commission’s report suggests.
The review, suggests that the NHS is only “scratching the surface” when looking at the quality of GP services outside normal hours, used by 9 million patients every year.
The inquiry was prompted by the case of David Gray, 70, a retired engineer who died after he was given 10 times the normal dose of diamorphine by a foreign GP employed by Take Care Now.
Mr Gray, of Cambridge, was treated for kidney pains by Dr Daniel Ubani, who had flown in from Germany and who admitted that he was tired when he made the fatal mistake. He has been convicted of causing Mr Gray’s death by negligence.
The commission’s report finds that the five NHS organisations that have used the Take Care Now company have not been monitoring the quality of the out-of-hours care. It says there are indications that it is a “widespread problem”.
The report also says Take Care Now has not been consistently referring patients who have suffered a suspected stroke to 999 services. Delays in treatment can lead to serious disabilities.
Cynthia Bower, the commission’s chief executive, said: “Primary Care Trusts need to reassure local people that they are commissioning good quality out-of-hours services.
“To do this they have to know what those services are doing. Our visits to the five trusts that commission Take Care Now’s services showed they are only scratching the surface in terms of how they are routinely monitoring the quality of out-of-hours services.
“We believe this may point towards a national problem.”
Take Care Now is employed by care trusts, in Worcestershire, Cambridgeshire, Suffolk, Great Yarmouth & Waveney, and South West Essex, covering more than two million people.
A detailed investigation will now examine the arrangements at the care company and a final report is due next year.
Campaigners say lessons have not been learned despite a series of high profile cases. They say out-of-hours care should be removed from private companies and handed back to GPs.
Katherine Murphy, the director of the Patients Association, asked: “Why do NHS managers need to be told that they should ensure out-of-hours care is safe? It is such a vital service, sometimes dealing with very vulnerable patients.
“There have been other cases where patients died when they received poor care from out-of-hours services. Why didn’t NHS managers act then? How many alarm bells need to ring before action is taken?”
Doctors’ out-of-hours services changed in 2004 with the introduction of a contract which offered them the chance to opt out of the service in return for an average drop in income of £6,000. In most cases, the trusts took over the commissioning of the services, employing private companies or co-operatives.
Prof Steve Field, the chairman of the Royal College of General Practitioners, said more family doctors needed to get involved in commissioning out-of-hours services.
“Out-of-hours provision is patchy,” he said. “Some PCTs are not effectively monitoring the performance of some providers.
“Providers need to ensure their doctors are competent to the level of UK trained graduates, have good English skills, are not over-tired after working long shifts and are orientated to the local conditions. What happened in Cambridgeshire was a tragedy and we need to ensure this never happens again.”
Two years ago Gordon Brown said NHS services at weekends needed to improve after the death of the journalist Penny Campbell, 41.
Miss Campbell died from blood poisoning in 2005 after consulting doctors employed by the out-of-hours provider Camidoc eight times over Easter weekend.
A report concluded there had been a “major systems failure”. Crucially, each doctor was not able to see the previous one’s notes. Miss Campbell’s partner Angus MacKinnon, a journalist from London, said yesterday that responsibility for out-of-hours services should be given back to GPs.
Mike O’Brien, the Health Minister, said: “PCTs have a legal responsibility to provide high quality, out-of-hours care and are required to have in place robust performance management arrangements to ensure their out-of-hours services are delivering against contractual requirements.”