A family whose three year old son died as a result of NHS errors has hit out at the time it has taken to find out what went wrong.
Sam Morrish died in December 2010 from the effects of sepsis, an illness that could have been treated if he had been assessed properly.
The Parliamentary Health Service Ombudsman (PHSO) found four separate health service organisations made repeated mistakes in his care.
Cricketfield GP Surgery, NHS Direct, out-of-hours service Devon Doctors Ltd and South Devon Healthcare NHS Foundation Trust made what was described as a "catalogue of errors".
The PHSO found there was an inadequate assessment made of Sam's illness, a failure to recognise he was vomiting blood and a three-hour delay before he received antibiotics when he arrived at hospital.
Ombudsman Dame Julie Mellor said had Sam received the appropriate care, he would be alive today.
But his family said as well as losing their son, their distress had been increased by the length of time it had taken for the PHSO to find out what had happened.
In a statement, they said: "The astonishing length of time it has taken for PHSO to finalise this report has inescapably prolonged our distress, as we have repeatedly had to revisit and relive the hardest day of our lives.
"Accordingly, although we are grateful that the PHSO has upheld our complaints, and we want to thank them for the clear recommendations that they have now made, we are left with serious concerns about the competence, capability and accountability of the PHSO itself.
"We pursued our complaints because we wanted to reduce the likelihood of the mistakes that were made in Sam's care, and the subsequent investigations, from being repeated.
"This was not only for the individual organisations that made those errors - but for the NHS as a whole.
Dame Julie Mellor said the NHS "needs to do more" "We never have been interested in blame. We have only ever been interested in learning and understanding, in the hope of change wherever necessary.
"Clearly we feel the complaints systems failed us, but it is important to note that we also believe it failed NHS staff too."
The family added: "Now the report has been published we hope that we will be free to concentrate on our futures, and on remembering our beautiful, sparkling, affectionate little boy, who we continue to miss every day."
Dame Julie said: "We've published this case so that the wider NHS learns from Sam's death and action is taken to help prevent lives being lost from repeated mistakes.
"Sadly, this case reinforces that the NHS needs to do much more to prevent avoidable deaths from sepsis."
Dr Graham Lockerbie, speaking on behalf of the local NHS, said it was "determined to ensure that the lessons really have been learnt".
"It's clear that there were shortcomings at every stage of his contact with the health service and that, in the words of the Ombudsman, Sam died when he should have survived."
According to the UK Sepsis Trust, the condition claims 37,000 lives in Britain every year.
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