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The health ombudsman's report displays "heartbreaking" cases where patient's suffering might have been prevented or even much less.
In one case in point, an individual had endured 14 tough tries to have a drip positioned in the time of his last hours.
The government proclaimed raising end-of-life care was a main priority.
The Parliamentary and Health Service Ombudsman has looked into 265 grievances with reference to end-of-life attention in the past four years, maintaining just over one half of them.
Catalogue of failings
Its Dying Without Dignity write up cited it had came across a large number of cases of undesirable interaction, in addition to bad pain control together with inadequate out-of-hours services.
1 mother told the ombudsman that she needed to contact an A&E medical professional to come and present her son a lot more relief of pain due to the fact team members on the palliative care ward he had stayed on had failed to deal with their wants.
In an extra scenario, a 67-year-old male's loved ones discovered his terminal cancer diagnosis by way of a hospital note - just before he was aware himself. This "neglected every single principle of established sound practice in breaking poor news", the review expressed.
"There was an unnecessary hesitation when making a diagnosis," it additionally mentioned. "A much earlier diagnosis should have made options for better palliative treatment."
Ombudsman Julie Mellor divulged to Radio 4's Today the document produced "truly painful reading".
The Ombudsman on top of that encouraged the NHS to learn lessons from the analysis, including: "The casework indicates that so many individuals are dying without dignity.
"Our studies have discovered that patients have spent their ultimate days in unneeded agony, individuals have incorrectly been turned down their want to die at their own home, and that poor verbal exchanges between NHS staff and families means that nearest and dearest had been unable to say their goodbyes to their loved ones."
Last moments
Roberta Sullivan's husband John was diagnosed with untreatable bile duct cancer in 2012.
He was told he only had a few days or weeks to live, although his condition deteriorated quickly overnight
Mrs Sullivan told the BBC she was not capable of being with him in his final moments for the reason that nursing employees had attempted to get in touch of her on an incorrect number during the early hours of the morning.
She pronounced: "By the time we had got to him they informed me 'we are extremely sorry but your husband has just passed away'.
"And I was told that you know we did attempt to contact you.
"But when I phoned my employer she said the hospital phoned twice in the night on my work phone number to try and contact you.
"I was a bit amazed by that. I waited until eight o'clock and spoke to the sister and explained it to her.
"And she stated the nurse is so remorseful. She's devastated that she accidentally phoned the wrong number and then sister apologised."
'Daunting incidents'
Macmillan Cancer Support chief executive Lynda Thomas expressed: "The review points out destructive instances of too little choice at the end of life that are totally unacceptable.
"If we are to further improve the current situation, we are going to have to see a dramatic development in co-ordination of care, and increased integration of health and social care."
The chief inspector of hospitals at the Care Quality Commission, Prof Sir Mike Richards, claimed the organisation had seen instances of great end-of-life care, but in addition instances where it was not given enough priority.
He explained the CQC would carry on and showcase those services which were failing.
A Department of Health spokesperson documented: "These are appalling cases - everyone should get top quality health care at the end of their lives.
"The five focal points for end-of-life care we introduced emphasise that medical doctors and nursing staff must include patients along with their families in decisions with regards to their care, regularly look at their treatment solution and reveal patients' choices to ensure their wishes are recognized.
"NHS England is focusing on making these focal points a real possibility for everyone who demands end-of-life care."
