A charity has been charity fined £450,000 after a woman in its care drowned in a bath.
The Richmond Fellowship Scotland housed Margaret Glasgow, 59, at Cherry Tree Court, Cambuslang, South Lanarkshire, for four weeks up until her death on June 10, 2016.
Jurors heard how staff helped keep watch on Margaret – who had severe autism and communication issues – during the day using a baby monitor.
She had also been able to leave her room without being noticed including wandering naked in the courtyard area.
Margaret also experienced an earlier trauma after flipping in the tub while being bathed and was not able to turn herself around.
The social care firm – who last reported income of £90.6m – was found guilty by a jury at Glasgow Sheriff Court to exposing Margaret to risks to her health and safety at their facility.
Sentencing, sheriff principal Craig Turnbull said the lack of water safety measures had put someone like Margaret at risk.
He said: “Between 1am and 2am, Margaret, without knowledge of the support workers, entered her bathroom, placed the plug in the bath, turned on the taps and climbed in, where she drowned.
“The jury established there were a catalogue of failings in the Richmond Fellowship Scotland.
“They failed to have a suitable plan in place to manage her movement (as well) as answer to her needs and measures required for her safety.
“The jury were satisfied that this caused Margaret’s death and in the present case I am satisfied that the harm caused could not have been greater.”
The court heard Margaret had complex needs “with no awareness to the risks to herself”.
Staff would use baby monitors to keep tabs on residents.
If staff were attending to another resident, there was no way of tracking the baby monitors.
Jurors were told Margaret was able to come out of her flat during the night into the courtyard without being heard.
Prosecutor Pat Callender told jurors in her closing speech: “The area manager said she was naked and alone which is unacceptable.”
Margaret’s legal guardian Nicola Storey of South Lanarkshire Council was not informed by Richmond Fellowship that she had left her flat.
She requested more funding for more staff to be in Margaret’s flat after the incident despite claims that it would “restrict her movements”.
The court was also told Margaret had earlier experienced problems while being bathed.
Miss Callender said: “We know Margaret flipped over in the bath face down on May 31 when she was being bathed.
“The member of staff said how Margaret was not able to turn herself around.”
The incident was not reported in her care support plan.
Staff also checked up on residents by looking past the front door of their flats.
Miss Callender stated: “All of this led to Margaret’s death, the risks to her were not understood or passed on.
“No measures were put in place to adequately protect her from getting in a running bath and turning on the tap.
“If these measures were put in place – simply practical measures – I would say that she would not have drowned.
“If clear instructions were given to staff when to turn water off this would have prevented Margaret dying.
“She died on June 10, 2016, and died alone.”
Lawyers for Richmond told the court changes had been implemented following the tragedy.