A retired miner from Sheffield was prevented from going home to die because of a string of errors by the five organisations tasked with looking after him.
The 77-year-old man, who suffered from Alzheimer’s and was unable to walk, was failed by the Moss Valley GP Surgery in Eckington, Chesterfield Hospital, Sheffield Council, Derbyshire Council and the local NHS, an investigation has found.
The sick patient told carers he did not want to die in hospital or a care home, but wanted to be with his brother, with whom he had lived all his life.
But a report by the Parliamentary and Health Service Ombudsman, and the Local Government Ombudsman, found the dying man’s wishes were ignored and ‘not dealt with appropriately’.
A meeting to discuss the case was delayed by a month, in which time the man - who is not named in the report - died in hospital 10 miles from his home.
The health ombudsman, Dame Julie Mellor, said: “This tragic case could have been prevented if the proper procedures were followed and a more joined-up approach taken to care.
“A series of delays meant a dying man’s wishes were ignored, and caused unnecessary distress to his brother.”
Carers feared the patient lacked the capacity to decide for himself where he wanted to die, but failed to carry out an assessment to see whether this was the case.
Dr Jane Martin, the local government ombudsman, added: “I welcome the steps the local authorities involved have taken to improve their services since these events occurred.
“I hope this case serves as a reminder to other authorities of the paramount importance of listening to patients and involving them and their families in the care planning process.”
The five organisations involved in the incident in 2009 have been told to apologise to the surviving brother, and must each pay him £200 - a total of £1,000.