Investigations into the deaths of elderly people in residential homes in Devon have resulted in more than 70 recommendations to improve care.
The Devon Safeguarding Adults Board carried out serious case reviews at three separate homes.
The board said while most care homes in the county were well run, scores of improvements were needed to ensure elderly people were kept safe.
It made 74 multi-agency recommendations.
Its report said agencies which need to consider and act on the recommendations include residential and nursing homes, Devon County Council, Devon and Cornwall Police, NHS Devon, the Care Quality Commission, South West Ambulance Service Trust and the board itself.
The recommendations fall within various categories including training, communication, resources and accountability.
One of the serious case reviews was triggered by 29 deaths at a residential home in a year.
Police did not establish any criminal concerns regarding the deaths, but the Devon and Cornwall force raised concerns about poor practice and policy on the part of both social services and health professionals.
Another review was carried out after an elderly woman was killed by a man living in the same residential home.
The board's report said doctors had warned the man suffered from paranoid delusions and had challenging behaviour, but this information had not been passed to care home staff.
Alan Wooderson, chair of the board, said the events which triggered the serious case reviews happened several years ago and "significant" measures had been taken by the organisations represented by the Safeguarding Adult Board.
"Improved safeguarding procedures are already in place to ensure better standards of adult protection," he said in a statement.