A hospital trust has apologised to the family of a man whose life support was switched off against their wishes.
The case, along with nine others, was part of a review by the Health Service Ombudsman into care of the elderly.
The unidentified man underwent a quadruple coronary artery bypass at Oxford Radcliffe Hospitals NHS Trust but suffered heart attacks afterwards.
Staff turned off his life support, despite his family's request that they delay doing so for a short time.
Elaine Strachan-Hall, the trust's chief nurse, said: "The trust's practice in 2007, at the time of this case, was to make sure that any 'do not resuscitate' decisions were discussed with the family.
"In this instance, it seems this procedure was not followed.
"We have reviewed our practice and introduced a trust-wide guide to staff on end of life care, and communication between the clinical team and relatives is now included as part of our staff training.
"Since this case, the trust has apologised to the family for the distress that was caused by the lack of communication."
The official report by the ombudsman said the NHS is failing to treat elderly patients in England with care, dignity and respect.
The ombudsman, which deals with serious complaints against the NHS, said the patients - aged over 65 - suffered unnecessary pain, neglect and distress.
Charities said the findings were "sickening", while the government admitted improvement was needed.