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A baby died from tuberculosis contracted from his father after medics failed to spot the disease in an x-ray almost two years earlier.
Five-week-old Luchii Gavrilescu, from Margate, died at the QEQM hospital on December 6 last year from what was thought at the time to be sepsis caused by bronchiolitis.
But a post-mortem revealed the tot had in fact caught tuberculosis (TB). His dad, Vlado Gavrilescu, had been unknowingly living with the infection, despite a lesion showing up on an x-ray of his lungs in March 2018 at the William Harvey in Ashford.
On January 15 - a day after his son's funeral and almost two years after that first x-ray - he went back to hospital for a CT scan due to a persistent cough and weight loss, and was given the shock diagnosis.
A report by the East Kent Hospitals Trust, which runs the sites in Margate and Ashford, confirms the "significant delay" in diagnosis meant Mr Gavrilescu's disease worsened. It also led to Luchii and others - including his partner Laura Cooke, her two other children Archie and Macie, and family friends - being infected.
A separate investigation into the baby's death states: "If the father’s TB had been detected and treated earlier, following the chest x-ray in 2018, Luchii’s death and transmission of infection to others could have been prevented."
It was described as a "missed opportunity".
Public Health England has now launched a probe looking at how far the "cluster" of TB infections has spread. This includes, according to the family, screening of those at the maternity unit at the QEQM, where Mr Gavrilescu stayed when Luchii was born in October 2019.
The lesion on Mr Gavrilescu's lungs could be seen on the chest x-ray taken two years ago at the William Harvey, where he was being treated following an assault, but it was not identified by the doctor at the time.
It has now been recommended all chest x-rays are formally reported on by the radiology department, who are experts in the field.
This probe is separate from another serious incident investigation being undertaken into Luchii's death, which was described as "avoidable" by hospital chiefs.
Ms Cooke, 29, from Margate, had continuously tried to get her baby treated in the week leading up to his death but was sent home twice, despite red flags pointing to a life-threatening condition.
Luchii was struggling to breathe, had mottled skin and wasn't feeding properly.
On his third visit to A&E, it was almost six hours before he was seen by a consultant, by which time it was too late to save his life.
A damning report revealed staff failed to recognise the severity of his symptoms and did not escalate the case to consultants, who were completely unaware of Luchii and his grave condition.
Ms Cooke says the family has been failed not once but twice.
"As a family we are so very angry and words will never be enough because nothing will ever bring our beautiful little Luchii home," she said.
"We sadly lost one little life due to being failed not once, but twice, and with so many failures.
"It nearly ended with losing Luchii's daddy too and it's just unbelievable how many people have been affected by this and are on treatment. It's like a pandemic all because of one x-ray two years ago.
"We shall go all the way to the end for you, Luchii.
"Your big brother and sister miss you so much, as do all family and friends - our lives have been ruined forever.
"I hope no other family ever has to go through and witness what we as a family did and are going through.
"Our heartache, tears and anger shall stay with us forever.
"Let's hope things really do change. None of us will ever step foot in that hospital trust again.
"It's scarred us all for a lifetime."
Mr Gavrilescu, who is from Romania, a country considered a high-risk area for TB, had been taken by ambulance to the William Harvey on March 7, 2018, after being abducted, beaten with a chain and stabbed in the head and shoulder.
As part of his assessment, a chest x-ray and a CT scan of his head were taken.
In line with the hospital trust's policy, plain chest x-ray films are not formally reported on by the radiology team, unless a clinician asks for specialist radiology opinion. Therefore it remained unreported.
Processes are now being put in place to ensure clinical staff receive and review x-rays.
A spokesman for East Kent Hospitals said the family continues to be supported and has been shown the initial report.
Dr Rachel Pudney, health protection consultant for Public Health England South East, says the organisation is working closely with the local specialist TB services and the hospital trust to identify and, where necessary, screen any close contacts related to this particular case.
She added: "Those who are identified as close contacts are being made aware of the situation, and given advice on the signs and symptoms of TB along with the action they should take if they feel unwell with similar symptoms, as a precaution."
Tuberculosis: Fact File
TB is a bacterial infection spread through inhaling tiny droplets from the coughs or sneezes of an infected person, according to the NHS website.
It mainly affects the lungs, but it can affect any part of the body, including the tummy (abdomen), glands, bones and nervous system.
TB is a potentially serious condition, but it can be cured if it's treated with the right antibiotics.
Symptoms include:
According to Public Health England, new cases of TB in England last year fell to the lowest levels since records began in 1960.
There was a 44% drop in new diagnoses from the peak in 2011 to 2018 (from 8,280 to 4,672).
