An elderly man failed to receive vital medication after a transfer to an £800-a-week nursing home in Bedford because of a system failure, a coroner said.
The inquest into the death of James Stewart, 84, heard he did not get some of his drugs at Manton Heights Care Home for two months before his death.
He had Parkinson's disease and dementia and transferred in February.
Home owner Ranc Care admitted the failures and said staff concerned had now left and a new team was in charge.
Coroner Thomas Osborne, in a narrative verdict, said a nurse failed to transcribe the full list of medication supplied by a previous care home.
Vital drugs were missed, but Mr Osborne could not say if this had contributed to Mr Stewart's death.
Claim for £10,000
Mr Stewart changed both care homes and GP surgeries at the same time and this was a factor, the inquest heard.
Manton Heights, Bedford Manton Heights has closed its nursing section and now provides residential care for older people
The coroner said he would write to the Clinical Commissioning Group to ask it to try to ensure proper systems were in place for making sure full medicine lists were transferred from doctors' surgeries to care homes.
Ranc Care said staff now telephoned existing GPs for the medication list and then made sure it was checked properly.
A Bedfordshire social services investigation concluded staff had not followed correct procedures and Mr Stewart's medication was missed from day one.
The inquest was told the Care Quality Commission inspected the home in April and "identified significant issues related to the chaotic processes for the administration, ordering and recording of medicines".