A care home firm was ordered to pay £145,000 today after a disabled teenager was fatally scalded in a bath.
Paraplegic Yelena Hasselberg-Langley, 18, suffered "excruciating agony" after being lowered into the hot water at a supported living centre in Owens Way, Oxford.
Lifeways Community Care, based in London, which runs the home, admitted health and safety breaches at a hearing last year.
Today, the company was fined £100,000 and ordered to pay £45,000 costs plus £15 victim surcharge at Oxford Crown Court.
Sentencing, Judge Patrick Eccles QC said: "The case evokes a great deal of pity for her suffering and a sense of outrage that her ensuing scalding injury and death could have been easily avoided.
"She was blind, paraplegic, epileptic and severely disabled. She had some power of speech but couldn't clearly communicate her distress when placed in the bath and she would have suffered excruciating agony before being taken to hospital."
After the incident, Yelena was taken to the city's John Radcliffe Hospital before being transferred to a specialist burns unit in East Grinstead.
The hot water left her so badly injured that she died there on August 31 2007, four days after the accident.
The Health and Safety Executive, which prosecuted the company, said the water was "excessively hot" at more than 44C (111.2F).
Oxford Crown Court heard the "vulnerable" teenager, who was the first long-term resident at the home, required 24-hour care.
Incontinence problems meant staff at the home were also responsible for bathing her twice a day.
But on August 27, she suffered 25 per cent burns to her body after she was lowered into the bath which had been run with "scalding water".
Judge Eccles said though the precise bath temperature was unknown, the taps were capable of delivering water at around 66C.
"She sustained burns to over 25 per cent of her body area as a result of the scalding water.
"Despite the best hospital treatment, Yelena died four days later," he said.
An HSE investigation following her death revealed that although the bath used was fitted with a special valve to prevent scalding, this valve was never set.
Staff at the home were also found to have no training in the risks of scalding and there was no requisite bath thermometer in place.
But Judge Eccles acknowledged the HSE investigation had failed to reveal who had fitted or failed to set the bath valve which could have prevented the tragedy.
And he said many firms had been involved in the installation and management of the baths at the care home, with none accepting responsibility for the events of that day.
He said Lifeways Community Care, which provides services to more than 350 care homes in England and Wales, had no reason to believe the valve had not been correctly installed.
But he added: "After seven weeks there was still no bath thermometer for testing the water and none of the staff had been trained to implement Lifeways' written policy for bathing service users."
Company policy requires bath water to be between 37C and 40C, he said, and staff are advised to physically test the temperature with an elbow or ungloved hand.
Passing sentence, Judge Eccles said he would not impose a "particularly Draconian" penalty, given the dangers of scalding water were already well known.
And he acknowledged Lifeways' previously "unblemished record" at its homes which provide care for around 1,200 people.
The teenager's death, he said, was an "isolated but serious lapse from those standards".
"The difficulty faced by this court in tragic cases like these however is to determine what level of fine is appropriate to reflect public disquiet at the unnecessary loss of life."
Turning to the teenager's family he added: "Not only have they experienced severe anguish but even now they all in their different ways were profoundly affected by feelings of bereavement, depression and guilt.
"No sentence can alleviate that pain or diminish Yelena's suffering before her death."
Her mother and stepfather sat quietly in the public gallery as the sentence was handed down.
Although a fine of up to £175,000 could have been imposed, the judge said he had taken into account a guilty plea to arrive at the figure of £100,000.
And he said Lifeways' status as a "not for profit enterprise", meant it was "not in the public interest" to impose a more severe penalty.Reuse content