A toddler died of leukaemia after medical staff failed to diagnose his condition despite numerous "red flags" and 35 separate visits to doctors and hospitals.
Ryan Bhogal died at Birmingham children's hospital on 11 September last year.
A coroner is writing to the 20-month-old's Wolverhampton GP practice to ask how his condition went undiagnosed for so long, the Birmingham Mail reported.
An inquest into his death heard of repeated failings to spot the "red flag markers" of leukaemia, including bleeding gums, bruising, a rash, a lump on his head and a tendency to fall over.
Doctor Prashant Hiwarkar, from Birmingham children's hospital, said a blood test in August, when Ryan visited New Cross hospital, would have detected leukaemia.
“If Ryan’s gums were bleeding on August 9 and still red and bleeding on August 18 this would be a red flag for me,” Dr Hiwarkar said.
“I would have asked for a blood test. I believe you would have seen signs of an abnormal blood count.”
Children diagnosed early with Ryan's form of aggressive leukaemia have a 40 to 60 per cent chance of survival, he added.
The coroner, Zafar Siddique, said he was particularly concerned the hospital did not have access to Ryan's GP records, which possibly prolonged the time taken to diagnose the symptoms as leukaemia and order a blood test.
During the inquest, Ryan's father, Kulvinder Bhogal, described watching his son die: “Seeing him lying there attached to a machine was heartbreaking. I walked away from the ward with tears in my eyes. He was my world.”
