A man with advanced lung cancer was sent home from hospital twice - and diagnosed with muscular pain.
Following an inquiry into the incident, the facility has been told to review its accident and emergency procedures and apologise to the man's family.
The patient had gone to A&E at Inverclyde Royal in Greenock, Inverclyde, on two occasions to complain about worsening neck pain and blood in his urine.
But doctors diagnosed Mr A as having a muscular neck condition and did not refer his case to senior medics.
He was later found to have lung cancer which had spread to the vertebrae in his neck.
Mr A's wife complained to the Scottish Public Services Ombudsman about the way he had been treated and said his cancer could have been diagnosed sooner if the appropriate tests had taken place.
Jim Martin, the Ombudsman, upheld the complaint and concluded the diagnosis was "not reasonable" in light of his symptoms.
After taking independent advice from a consultant in emergency care, a respirator consultant and a urology consultant, he said in his determination: "We found that there had been issues in the two attendances at the A&E department.
"The advice we received was that the diagnosis that Mr A had received was not reasonable and that other issues had not been appropriately considered.
"The A&E adviser highlighted that after Mr A's second attendance, it would have been reasonable to discuss his case with more senior doctors."
The health board has been told to apologise to the family for "failings in his care" provided by the hospital, and to also review procedures for referring patients with symptoms that could suggest a serious health problem to more senior doctors.
A spokeswoman for NHSGGC said: "We have today received the Ombudsman's decision letter and fully accept the recommendations.
"We will be formally writing to the family offering our sincere apologies for the failings in this patient's care and to reiterate our sympathies for the family's loss.
"We have already put in place an action plan to ensure that patients presenting with progressive symptoms are escalated to more senior staff for further review.
"We have also discussed the complaint with appropriate staff and will share the Ombudsman's findings with the local Senior Management Team."
This incident comes amid calls for better co-ordination between health bodies and cancer organisations to boost survival rates from lung cancer.
Scotland and Wales fare worse than Northern Ireland and England, and the UK Lung Cancer Coalition said a new IT system used in England for auditing lung cancer could double survival rates.
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