One Serious Case Review was at Parkfields care home in 2011.Concerns were raised by staff members in 2007 regarding the registered manager and who was also a registered nurse, which led to a 3 year police investigation and during this time was charged with murder of two residents’. The registered manager was cleared of the murder but was found guilty of manslaughter of one resident and also sentenced for misappropriation of drugs and perverting the course of justice. The manager had a long history of suffering from migraines and pharmacists had contacted the GP on two occasions regarding the prescribing to the manager, also the surgery had reported to the GP concerns of the manager requesting prescriptions more frequently. During the trial it was admitted by the registered manager that she was addicted to opioid drugs and admitted possessing class A and C drugs. She was sentenced to 10 years. The purpose of the Serious Case Review was to find out whether there were lessons to be learned about the way that professionals and agencies work together to safeguard adults in the period up to January 2007.During the time leading up to the trial many improvements had been put in place to ensure the safety and running of the service. Even though it was not determined if improvements had been made earlier, the events that had taken place could have identified the manager’s behaviour.Lessons have been learnt by all the organisations involved, through the SCR process and also by professionals own responses after the events. An action plan was implemented with many actions agreed, who is responsible and a timescale to the actions being completed. Recommendations were that bodies responsible for the training and development working in care homes should include information on the accountability of registered nurses who are also registered home managers, care home providers must only accept resident’s that fall in their registration, monitoring resident’s changing needs. Reviews should be holistic and include information and medication reviews, Validation of the CPD records of nurses employed in more isolated settings such as care homes, new regulatory systems need to be made aware to the public by CQC and also take the findings of the review into account in its revised inspection. NHS organisations review the safeguarding training required for different professionals and their duty to be alert and report vulnerable adults, End of life care should be implemented in all care settings, all relevant persons should be reminded statutory requirements under controlled drugs regulations 2006 and sharing of information to relevant person’s. Controlled drugs should not be on repeat prescription and should be reviewed regularly by GP’s, the safe dispensing administration and monitoring of controlled drugs, auditing continuously and concerns raised immediately, ensuring policies & procedures are reviewed, Whistle-blowing policy updated and considering the effectiveness of supporting whistle-blowers, including record keeping and drugs administration are implemented and audited. When patient’s move from GP to another practice there needs to be a more robust expectation about sharing of concerns regarding individuals and a flag system for patient’s on controlled drugs. An appropriate senior should be available to support staff during an investigation. Actions had been completed within a year but with some actions that were ongoing.