NHS bosses have been criticised over an "avoidable" three month delay in diagnosing a man's cancer after doctors missed an abnormality in his CT scan.
By the time the man, known as Mr A, found out about the illness it was incurable. He died the following month.
The case was revealed after the man's father complained to the Scottish Public Service Ombudsman (SPSO).
Mr A was initially referred by his GP to the Royal Alexandra Hospital in Paisley suffering from breathlessness.
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Two chest x-rays and a CT scan were performed over the following months.
Although this initial CT scan detected an abnormality, this was not reported at the time and "resulted in an avoidable delay of approximately three months in the diagnosis of Mr A’s cancer".
The watchdog also criticised the fact that Mr A had to chase up the result of the CT scan himself after it was left on the desk of a consultant who had actually retired.
In its report on the case, the Ombudsman stated: "We found that the scan result had been left on a consultant’s desk awaiting dictation, and the consultant had retired.
"It took Mr A’s prompting before a secretary arranged for another consultant to review and share the result.
"Mr A received the result ten weeks after it had been reported. We considered this delay was unreasonable and that a more robust system was required."
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In the meantime, Mr A's condition had deteriorated. Seven months after he was first seen at the RAH he attended A&E with severe pain in his side and back.
Later that same month, he suffered a fall and was admitted to hospital where a further X-ray and CT scan were carried out.
A biopsy subsequently confirmed that he had terminal cancer.
NHS Greater Glasgow and Clyde has apologised to Mr A's family for not picking up the cancer in his first CT scan. The Ombudsman said this error will be discussed at a "learning meeting" for clinicians.
However, the health board has also been ordered to apologise for the "unreasonable delay" in informing Mr A of the CT scan results, and for failing to properly address his father's complaint about this delay after his son's death.
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The Ombudsman added that "there needs to be a robust system in place for reviewing and communicating imaging results".
It has told NHS GGC to review their system to avoid a repeat of the circumstances which led to delays in Mr A's case.
A spokeswoman for the health board said: "We recognise there were failings in this patient’s care and have written to the patient’s family to apologise.
"The Ombudsman’s recommendations are being discussed by a multi-disciplinary team to identify how these can be quickly implemented and ensure that lessons learned in this case are shared with the appropriate staff."
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