A GP surgery in Norfolk was "allowed to slip beneath the managerial radar", says an independent report.
A review was commissioned by the NHS East of England's chief executive Ruth May to investigate Downham Market Health Centre following four "serious incidents", GP suspensions and a patient death.
The review, which investigated the centre from March 2010 and March 2011, argued the practice should have been treated as "high risk" and showed a "deficiency in safe general practice".
Evidence from the report appears to show locums were recruited by receptionists following GP suspensions.
"When [the second GP] was suspended, it was the initiative of the receptionists that secured a locum for the next day," said the report.
"It is not surprising therefore that processes of recruitment, induction and supervision were lacking.
"It should be noted that these issues were present during the time of temporary practice managers appointed by Norfolk Community Health and Care who did not ensure that these processes were adequate."
Although the report highlighted bad management practice, it acknowledged there were no "definite examples" where patients had come to harm.
It also praised staff for their "remarkable" performance under "difficult circumstances".
"Despite the practice sliding into managerial failure, the staff held it together, going well beyond their job descriptions to ensure the provision of care to their patients," said the report.
South West Norfolk MP Elizabeth Truss has said the report does not "go far enough" and will report her concerns to the Secretary of State for Health Andrew Lansley.