Five elderly care home residents died within two weeks of each other after suffering "severe neglect", an official inquiry has concluded.
The residents of Parkside House Nursing Home in Northampton died between July 22 and August 6 2009.
A Serious Case Review into the deaths found there were some warning signs of a decline in standards at the home, but it was only when one elderly woman was admitted to hospital that the alarm was raised.
She died in hospital and over the next two weeks four other people aged between 83 and 100 also died.
The Northamptonshire Safeguarding Vulnerable Adults Board (SOVA) said an action plan had been put in place to prevent the situation being repeated.
Independent chairman Marie Seaton said the residents had died in circumstances that "none of us would wish our mothers or fathers, or sons or daughters, to die in".
She said: "Although it is not possible for us to know for sure what was happening at Parkside House during this time, the review has shown that there were warning signs that the management of Parkside was failing to deliver leadership required to ensure a clear focus on resident safety and well-being."
Northamptonshire County Council, which had placed five residents in Parkside House - two of whom were among the five who died - said the residents did not receive the level of care they deserved.
Corporate director of health and adult social services Charlie McNally said: "It's clear that these people were let down by the quality of management and nursing care in this home."
