The deaths of two vulnerable people living in the same Norfolk care home, including a woman who died after she was pushed over by another resident, have triggered major reviews.
The death of a man who died just days after he was admitted to the home following release from a psychiatric hospital is one of the two cases which have been investigated.
The two deaths at the care home, which has not been named, were not connected, but sparked what are known as safeguarding adult reviews.
The reviews, called for by the Norfolk Safeguarding Adults Board (NSAB), started in January 2019 and will soon be published.
The woman who died had been pushed over by another male resident, fracturing her hip.
She was taken to hospital and, after a spell being treated there, returned to the home.
But she died about three weeks later.
In the other case, the man who died had frequently been in and out of acute hospital and psychiatric hospital.
He was discharged from a psychiatric hospital and went to live at the care home.
But, after 11 days, he was admitted to hospital due to ill health and died in hospital the next day.
The deaths led to the reviews, the purpose of which is not to apportion blame to any individual or organisation.
The aim of such reviews is to ensure lessons can be learned and improvements made where a vulnerable adult has died, or been seriously injured, and where abuse or neglect is suspected.
The NSAB, which is made up of representatives from councils, police, public health, hospitals, clinical commissioning groups, the University of East Anglia and others, considered and agreed the report and its recommendations at a meeting in September.
And, in the middle of next month, the reports and findings will be made public.
The board said: "The recommendations from these reviews will provide Norfolk with valuable learning regarding the care of people with dementia in care settings, where mental ill health is also of concern."
They added that: "Comprehensive action planning has been under way since the report was approved, to establish how the board and its partners will address the recommendations."
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