An ambulance should have taken a frail, sick woman to hospital, according to the health ombudsman.
The woman, in her eighties, was vomiting and developed diarrhoea.
Her carer in Cambridgeshire called an ambulance but the paramedic decided the woman's condition could be managed at home.
That evening, the carer made another 999 call and a paramedic, reluctantly, took the woman to hospital.
She died soon after.
The ombudsman's investigation found the woman should have been taken to hospital after the first 999 call and although the delay did not cause her death, it caused her avoidable distress, discomfort and loss of dignity.
A spokesman for the East of England Ambulance Service NHS Trust said: 'We recognise that the first paramedic should have taken the patient to hospital, and have apologised to the patient's daughter. The steps the Trust has taken to prevent incidents like this happening again include focusing on attitude and patient communication, and introducing supervisory roles to support staff in delivering improvements to care for our patients.'
The case, which took place in Cambridgeshire, is one of several examples released by the Parliamentary and Health Service Ombudsman on Wednesday.
No further details about the case were released by the ombudsman.
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