A two-year-old boy who died of a brain tumour may have been cured if doctors had spotted it, a coroner has ruled.
Max Earley died after a series of blunders meant his brain tumour went undiagnosed for several weeks and ultimately killed him.
An inquest at Westminster Coroner's Court heard that his mother "watched him die" as doctors struggled to diagnose his condition, despite it showing up on a CT scan.
The inquest heard that one doctor incorrectly read the scan, missing the tumour, while other doctors thought the scan had been reviewed by experts at Great Ormond Street Hospital when in fact they never looked at it.
Max, who was 27 months old when he died, first fell ill in August 2012 when he began vomiting constantly.
He was admitted to Hillingdon Hospital in Uxbridge, west London, where a CT scan was carried out amid fears he might have a brain tumour.
But the scan was missed by a consultant radiologist and as another test showed up a potential hernia, Max was transferred to London's Chelsea and Westminster Hospital, where doctors searched for a possible gastro-intestinal cause of his illness.
An MRI scan. which would have shown the tumour, was "put on hold" while doctors looked at possible gastric problems and, after being allowed home, Max was readmitted to Chelsea and Westminster in September and his condition steadily deteriorated.
On the night of September 23 his condition became acute and he was rushed to Great Ormond Street, where the tumour was finally diagnosed. But despite emergency surgery to remove some of it, Max never recovered and died on September 28 2012, aged 27 months.
After the two-day inquest, coroner Dr Shirley Radcliffe gave a narrative verdict finding that there were several errors, including the misreading of the CT scan at Hillingdon, and a later review of the scan. This only looked at an unenhanced scan, which looked normal, but staff had not been told there were other enhanced scans.
The coroner said the evidence at the inquest was that the tumour was removable up until Max deteriorated on September 23, adding: "A complete resection would have, on the balance of probabilities, resulted in a good chance of cure."
But she said both Hillingdon and Chelsea and Westminster Hospitals had made changes to their radiology processes to make sure similar circumstances did not happen again.
Giving evidence at the inquest, Max's mother Car oline Earley, from Harefield, near Hillingdon, described how she told doctors she was watching her son die.
Today she and Max's father Vladimir Earley said: "We are at a loss to understand how in a modern healthcare system Max's brain tumour was not properly identified for a month since it was first suspected.
"In that time Max had got weaker and weaker, he lost weight and must have been in terrible pain at times. He was too young to tell us how he was feeling and we are saddened beyond words that we could not help him despite having placed him in the hands of the doctors. He had to endure many painful medical procedures that would have been avoided with proper care.
"The coroner found that there was a serious failure at Hillingdon Hospital to read Max's CT scan and that the failure of communication between the doctors at Chelsea and Westminster meant that the same CT scan was not acted on again.
"We did our best for our child but there were times when we weren't listened to and Max's changing behaviour was not appreciated.
"Towards the end, Max's father had to hold his son while he had a prolonged seizure which was not recognised as such, despite his attempts to get help for his son. If his tumour had been diagnosed, Max's life would have been saved."
Mrs Earley urged all parents and medical professionals to visit the website of HeadSmart, a project that aims to enhance the awareness of symptoms of brain tumours in children and young people, and get one of its credit card-sized guides which helps people spot the signs.
A spokeswoman for the Hillingdon Hospitals NHS Foundation Trust said: "The Hillingdon Hospitals NHS Foundation Trust would like to offer its condolences to Max Earley's parents.
"It notes the findings of the coroner's investigation and hopes that Max's family is reassured by the actions put in place since his death."