The medical director of one of Britain's top cancer specialist hospitals has admitted mistakes were made in the care of a toddler who died after doctors failed to spot her fatal brain condition in time to save her.
Two-year-old Alice Mason had successfully undergone treatment for a brain tumour two months before she was taken ill in March 2011.
She died days later, having developed fluid on the brain, an inquest at West London Coroner's Court heard.
Rosalind and Gareth Mason claim that a catalogue of chances to act on their daughter's symptoms were missed and staff at one hospital told them a CT scan was unnecessary.
The youngster's care was shared between her family's local district general hospital, Kingston Hospital in Surrey, cancer specialists at the Royal Marsden Hospital, in Chelsea, west London, and a neurosurgical team at St George's Hospital, south London.
Professor Martin Gore, medical director of the Royal Marsden, who led an inquiry into Alice's care at the hospital and Kingston Hospital following her death, found more than a dozen failings by medical staff.
Coroner Dr Sean Cummings said the report had shown failures at "almost every pathway" of care given to the toddler including unclear information about her MRI scan, inadequate communication, lack of overall care plan, lack of monitoring of her hydrocephalus - or "water on the brain" - and a failure to listen to Alice's parents.
"I find this astonishing given Royal Marsden is a not only a centre of excellence but a top centre of excellence," the coroner added.
Prof Gore told the inquest Alice's death had "shaken many, many people within the organisation".
"I don't think anyone involved in this case will forget it," he said. "I certainly won't."
Lawyers for the family say Mr and Mrs Mason were told at the Royal Marsden on March 23, 2011 that an MRI scan had shown some signs of fluid accumulation and Alice should be taken to Kingston Hospital if her symptoms worsen for a CT scan.
But when Alice was taken to Kingston Hospital hours later, a junior doctor stated that it was not in her clinical judgment that a CT scan was required, according to the Mason's legal representatives Leigh Day.
The doctor, Sharon Jheeta, told a previous hearing that as a junior she would not have made such a decision and that all the decisions about Alice's treatment were made by more senior staff, Leigh Day said.
By the time the tests were carried out at Kingston Hospital, Alice had suffered irreversible brain damage, caused by hydrocephalus, and emergency surgery could not save her.
Lawyers for the family claim there were also further delays in transferring Alice to St George's Hospital and in the surgery taking place.
She died at home on March 31 2011 having suffered irreversible brain damage as a result of hydrocephalus.
Prof Gore insisted Royal Marsden hospital had "learnt lessons" following Alice's death.
"I think there are some things that are unlikely to happen again," he told the inquest.
"I'm not going to say never but several lessons have been learnt across all three trusts."
He added: "I think it's also important to point out the clinical circumstances - that is not to excuse what happened.
"This was not a child who was completely well, without anything else going on."
Asked by the family's lawyer Jeremy Hyam whether there was a "grossly sub standard of care delivered to Alice", he replied: "No I don't accept that.
"To say that is to imply that the clinicians ignored what was going on.
"Yes there were mistakes. That's not the same as not caring."
Mr Hyam read a note handed to him by Alice's parents which labelled many of report's recommendations as "basic" guidelines which should already have been in force.
"I don't think basic care was lacking here," Prof Gore said. "People were not ignoring what was going on.
"Yes, wrong diagnosis were made but when looking at the traffic of telephone calls there was a lot of care.
"People were trying to get to the right answer.
"A lot of work has been done to repair what we found as a result of the investigation.
"We are continually testing our systems to make sure this doesn't happen again."
Dr Stergios Zacharoulis, consultant paediatric oncologist from the Royal Marsden Hospital, told the inquest he was not informed that Alice's mother had called the hospital on March 17 to say her daughter had become "wobbly" after chemotherapy.
"For some very bizarre reason I was not informed," Dr Zacharoulis said.
"It was a total failure. I should know about this but unfortunately I didn't."
The doctor said he was also not told that Mrs Mason had reported her daughter was unable to walk unaided and was suffering from an increased fatigue when she arrived for an MRI scan on March 21.
Both incidents were recorded in the electronic patient record (EPR), the court heard.
Dr Zacharoulis said he went to Royal Marsden's MRI department on March 23 to discuss the results of the scan, which had shown abnormalities, but the appropriate staff were not there.
The scan results were also not discussed by specialists in charge of Alice's care in a multi-disciplinary meeting because a radiologist was not present, the inquest was told.
Dr Cummings said: "I'm concerned that there seems to have been a sequence of issues in terms of communication when Alice was seen on March 21.
"I'm finding it difficult to see why if you went to the MRI department to ask on the 23rd, you were concerned enough to go an ask but because there wasn't anyone there you left it until the next day.
"I'm not sure that there was a significant grip on this."
"I wish I had done the CT scan straight away," Dr Zacharoulis told the inquest.
"I wish in Alice's case, and this is extremely painful, that I'd have called the consultant myself," he added.
Expert witness Christopher Chandler, consultant neurosurgeon at King's College Hospital, told the inquest that Alice was in "time critical territory" by March 26.
"Once the patient's level of consciousness is deteriorating, you're in time critical territory," he said.
A third of patients with the tumour suffered by Alice may develop hydrocephalus, he added.
The MRI scan had indicated the youngster may have water on the brain, sepsis or a possible recurrence of her tumour.
Asked whether a medical procedure known as a lumbar puncture should have been performed by March 21, he replied: "A lumbar puncture would have confirmed or refuted the diagnosis.
"It's a way of ruling out of hydrocephalus."
The inquest, which is expected to last four days, was adjourned until tomorrow.