British hospital staff called the wrong family to come and say goodbye to mother on a do-not-resuscitate order.
London's Telegraph reports that nurses mixed up the next-of-kin number, meaning that the family of Avril Chadwick were not consulted about the DNR notice, or able to be with her when she died.
The mother-of-six was admitted to University Hospital in Coventry on February 27 last year with pneumonia. Her condition was critical but she was expected to survive, according to the Telegraph.
Three days later she was moved to a cardiology and respiratory ward where she deteriorated after doctors stopped her IV fluids without her family's consent.
The Telegraph article claims that staff then mistakenly called Linda Allen, whose mother was recovering from minor surgery on the same ward, five times advising her to come in as soon as possible to say her goodbyes.
During one call Mrs Allen even told nurses she was with her mother who was sat up in bed, chatting and drinking a cup of tea, the Telegraph reports.
At the same time Mrs Chadwick's husband Thomas, 62, and daughter Jodie, 28, were oblivious her condition had deteriorated and stayed at home just 5km away.
When her daughter phoned just minutes after Mrs Chadwick had passed away the nurse refused to allow her to visit, the story claims.
Weeks later the hospital admitted calling the wrong family.
Ms Chadwick, from Coventry, said: "We had been up there the whole time because of how ill she was but she died on her own, probably scared and all on her own. It breaks my heart to think of her dying without any of us around her. A mother is the one person you can't replace. It's like a piece of us is missing."
Mr Chadwick, who gave up his work as a builder to care for his wife of 41 years, is now considering suing the NHS .
Mark Radford, chief nursing officer, apologised and admitted it should never have happened, adding: "A very simple error led to serious consequences for Mrs Chadwick's family and led them to feel unnecessary distress at a very difficult time.
According to the Telegraph the nurse who made the error has not been disciplined and is still working in the hospital.