The death of a woman with learning difficulties who died after being scalded in her bath was a "preventable" accident, a Sheriff has ruled.
Margaret Gilchrist, 50, sustained scalding to 80-90% of her body after her carer left the hot tap running in the bath.
Following a Fatal Accident Inquiry (FAI), Sheriff Lindsay Wood said that carer Mary Cameron committed an "enormous human error".
He concluded that the accident would have been avoided if the hot water tap had not been left running and might have been prevented if visual checks had been made every three minutes or less.
In his written judgment Sheriff Wood said: "Tragically, Mary Cameron did not ensure the hot water tap was turned off before she went downstairs to attend to various matters.
"As a result, the hot water continued to flow from the tap and the temperature became increasingly excessive as the thermostatic mixing valve (TMV) did not function properly.
"Consequently, Margaret was scalded by the hot water and thereafter died.
"Between 80% and 90% of her body had been scalded as unfortunately, Mary Cameron had left her in the bath for longer than usual, certainly in excess of 30 minutes.
"If she had been checked regularly during that time, Mary Cameron may well have seen the distress being caused and might have been able to do something about it."
He added: "She died in an accident which was preventable."
Ms Gilchrist had a severe learning disability, was registered blind and had epilepsy and was receiving support 24 hours a day, seven days a week.
She lived in the Carntyne area of Glasgow in a Glasgow Housing Association (GHA) owned property leased to Enable Scotland, which provided the support service out of an allocated budget provided by Glasgow City Council (GCC).
On the evening of her death on September 26 2013, Ms Cameron ran a bath for Ms Gilchrist, then left her alone while she was busy downstairs.
She dialled 999 after finding Ms Gilchrist unresponsive in the bath and she was pronounced dead at 8.08pm.
A post-mortem examination found that scalding injuries while alive were a "significant contributory factor" in her death.
The Sheriff also said that if the old TMV had been replaced with a new one it is possible the latter may not have malfunctioned and there would not have been hot water scalding.
The Sheriff made no criticism of GHA or GCC in respect of matters which might have contributed to the death, and noted that Enable Scotland has made changes as required.
An ENABLE Scotland spokesman said: "The thoughts of the ENABLE Scotland family are with Margaret Gilchrist, who was a much-loved lady.
"This was a tragic incident, and today we are thinking of all who knew and loved Margaret.
"ENABLE Scotland is committed to providing high quality outcomes for the people we support, and to ensuring that the best care is in place for some of Scotland's most vulnerable people who have a learning disability.
"The inquiry identified an area of the working system, which at the time of the incident in 2013 could be improved upon; and acknowledged that ENABLE Scotland took prompt action at that time to address it.
"We will now further reflect on the full findings made in the Determination.
"The dignity and wellbeing of the people we support continue to be our highest priorities."
A GCC spokesman said: "We note the Sheriff's comments in relation to the council. Our thoughts are with the family."
The FAI took place at Glasgow Sheriff Court on 16 days between November 2015 and September 2016 with a further hearing on October 21.
A GHA spokesman said: "We offer our sincere condolences to Margaret's family.
"We are reviewing all aspects of the Sheriff's determination, notwithstanding that in respect of matters which might have contributed to Margaret's death, he offered no criticism of GHA.
"As a responsible landlord, we will continue to take all reasonable steps and do all we can to ensure everyone is safe in their homes, particularly the vulnerable."
Why are you making commenting on The Herald only available to subscribers?
It should have been a safe space for informed debate, somewhere for readers to discuss issues around the biggest stories of the day, but all too often the below the line comments on most websites have become bogged down by off-topic discussions and abuse.
heraldscotland.com is tackling this problem by allowing only subscribers to comment.
We are doing this to improve the experience for our loyal readers and we believe it will reduce the ability of trolls and troublemakers, who occasionally find their way onto our site, to abuse our journalists and readers. We also hope it will help the comments section fulfil its promise as a part of Scotland's conversation with itself.
We are lucky at The Herald. We are read by an informed, educated readership who can add their knowledge and insights to our stories.
That is invaluable.
We are making the subscriber-only change to support our valued readers, who tell us they don't want the site cluttered up with irrelevant comments, untruths and abuse.
In the past, the journalist’s job was to collect and distribute information to the audience. Technology means that readers can shape a discussion. We look forward to hearing from you on heraldscotland.com
Comments & Moderation
Readers’ comments: You are personally liable for the content of any comments you upload to this website, so please act responsibly. We do not pre-moderate or monitor readers’ comments appearing on our websites, but we do post-moderate in response to complaints we receive or otherwise when a potential problem comes to our attention. You can make a complaint by using the ‘report this post’ link . We may then apply our discretion under the user terms to amend or delete comments.
Post moderation is undertaken full-time 9am-6pm on weekdays, and on a part-time basis outwith those hours.
Read the rules here