An NHS inquiry is to be held into how a former care home manager in Somerset was able to siphon off prescription drugs from the elderly people she nursed, the BBC can reveal.
Rachel Baker, 44, was sentenced to 10 years in prison in May for the manslaughter of 97-year-old Lucy Cox with a lethal dose of painkillers at the Parkfields Residential Care Home, in Butleigh, Somerset.
But her imprisonment does not go far enough for those who claim a number of other residents who died at the home were also killed. They want an independent inquiry and their MP, Tessa Munt, has agreed to help them.
Baker had been addicted to the very painkilling drugs she was supposed to be giving to her residents. During her trial, it emerged she fabricated terminal conditions and exaggerated symptoms of her residents in order to feed her habit.
At one stage, police were investigating up to 12 suspicious deaths in an inquiry which saw them exhume the bodies of former Parkfields residents Nellie Pickford, Marion Alder and Fred Green.
But in the end, no murder charges were pursued from the exhumations. As the bodies had been in the ground so long, there was no clear evidence of how they died.
But some relatives of residents who were looked after by Baker are now asking whether their loved ones would still be alive today if they had been sent elsewhere.
NHS Somerset is undertaking a review to identify any lessons that could be learnt from Baker's case.
The review will involve meetings with the police officers who gathered evidence and consideration of the issues raised by the trial about the home's general practice.
And it will investigate how Dr Richard Hughes - the main GP for both Rachel Baker and her residents - prescribed powerful painkillers on her say-so alone.
The review will also look into why Dr Hughes continued to give Baker drugs for her residents for several months after colleagues recognised her addiction and said they should no longer prescribe the nurse painkillers for her own use.
Director of nursing and patient safety for NHS Somerset, Mary Monnington, will be carrying out the review.
She said: "I think the view among the GPs generally was that having withdrawn the medication, which appeared to be leading to a degree of dependency, they had resolved the problem of dependency in Rachel Baker.
"In terms of prescriptions for individual patients, this was a practice that had taken place at the home without any undue problems over a period of eight or nine years preceding this and I think the GPs believed that they were dealing with a professional whose problem was now resolved."
NHS Somerset has pointed out that the judge did not criticise any GPs in his summing up at Baker's trial.
While some families have welcomed the review, they say it is not enough.
The daughter of 79-year-old Marion Alder has met with Ms Munt to call for a public inquiry.
Claire Forsey, 49, said her mother had been denied the drugs she was prescribed to treat her severe anxiety disorder because Baker was taking them.
"She took their drugs and left them, in my mother's case, making her so anxious that it was just tortuous.
"For the last six months of her life she was like a frightened rabbit caught in headlights and bewildered by what was going on."
The former carer at the home who blew the whistle on the scandal, Sarah Barnett, is delighted Ms Munt has offered to help in pushing for an independent public inquiry.
Mrs Barnett, 40, said: "Independent scrutiny is obviously safer and having more public awareness... into governing bodies, or the situation, is a safer process and ensures more accountability."
However she called for the inquiry to also examine the role of other agencies, such as the care home inspectors.
Ms Munt said she wanted to work with the families to "make sure that we sort out some of the issues that we have identified so that we can make things better for everybody else".