Two families of two people who died in a Devon hospital have had complaints about poor nursing care upheld by the Health Commission.
Ron Martin (l) and Stan Rogers died in Whipton Hospital
Complaints by the relatives of Stan Rogers and Ron Martin, both from Exeter, covered safety, hygiene and nourishment at Whipton Hospital.
Devon Primary Care Trust has apologised and said a review would be carried out.
But the families have said they now intend to take their complaints to the health ombudsman.
Pat Martin's father, Ron, died of cancer at the community hospital in July 2006.
'Get things wrong'
She said he fell over four times, received poor care and on the night he died was left vomiting and in pain.
"We've got to keep pushing to ensure that no other individual, especially a frail, vulnerable person, has to go through this again," Ms Martin told BBC News.
The Healthcare Commission upheld several aspects of the complaint by Ms Martin.
It also upheld a complaint by Jennifer Leach, whose 93-year-old father Stan Rogers died after falling at least seven times.
Trust spokeswoman Jan Ingram said: "The NHS is a caring organisation, but occasionally we do get things wrong.
"Where we do, we need to make sure we learn the lessons."
The action plan includes tougher measures to prevent falls, more help for patients with eating and drinking, training to ensure staff keep proper records of care and controls to ensure only suitable patients are admitted.