The teenager suffered severe burns when she was lowered into the hot bath at a supported living home in Oxfordshire.

The care home provider was sentenced after being prosecuted by the Health and Safety Executive (HSE).

The teenager was a resident at the home and required 24-hour care. She was registered blind, was paraplegic and also had epilepsy.

On 27 August 2007 she was lowered into a bath of hot water and suffered severe burns. She was admitted to the John Radcliffe Hospital in Oxford before being transferred to the specialist burns unit at the Queen Victoria Hospital in East Grinstead. She died on 31 August 2007.

The care home provider pleaded guilty to breaching Section 3(1) of the Health and Safety at Work Act etc 1974.

This was a successful joint investigation which was initially led by Thames Valley Police (TVP) with technical assistance from HSE. The TVP report was passed to the Crown Prosecution Service who decided that they would not pursue criminal proceedings against any of the individuals involved. The HSE then continued with the criminal investigation.

The court heard that the HSE investigation found that although the bath was fitted with a special valve to prevent scalding, this valve had never been set. Staff had also received no training in the risks of scalding and there was no bath thermometer.

Following the incident an Improvement Notice was issued by the HSE to the care home requiring them to establish proper procedures to minimise the chance of a similar incident occurring.

An inspector commented:

"It is difficult to imagine a more vulnerable resident. The risk of scalding to people who are so vulnerable that they cannot prevent harm to themselves is a well-known danger in the care industry.

The consequences of scalding can, in addition to causing excruciating pain, be fatal - as so shockingly seen in this case.

Everyone involved with the care of vulnerable service users must ensure that they have the necessary safeguards in place. Cases like this are completely avoidable if the correct guidance is followed."