A care home firm was fined £537,000 today after one of its residents died from a fire in her room.
HC-One Limited admitted a health and safety breach at Glasgow Sheriff Court.
Carol Hughes, 54, was found in her bed by firefighters in Glasgow's Arcadia Gardens on March 25, 2017.
She was found to have suffered burns between 65% to 75% and severe smoke inhalation which later caused her death in hospital.
An e-cigarette and a lighter were found on her bed while a further lighter was found nearby.
A hearing was also told that the fire alarm in Carol's room did not correspond to the correct zone on a chart resulting in the wrong area being evacuated.
Carol - who had recently refused to leave her bed - did not have her smoker's care plan reviewed as a result which exposed her to a level of risk.
Carol - who suffered from multiple sclerosis - was a resident at the care home in the city's Bridgeton from November 2015.
She was stated to be a regular smoker of cigarettes and e-cigarettes.
The care home had a designated smoking area for residents.
The court heard that Carol had begun refusing to leave her bed on occasions around early March.
Around 4.25pm on the day of her death, an alarm was activated which stated there was a fire in a "zone" which covered the kitchen of the care home which was adjacent to Carol's room.
The area was evacuated but was later found to contain no fire.
Smoke was then discovered coming from Carol's room which could not be accessed to evacuate her.
Fiscal depute Saud Ul-Hassan said: "At 4.50pm, Carol, while suffering from severe smoke inhalation, was discovered by the fire brigade in her bed."
She was taken to hospital with her injuries and given palliative care until she passed away at 9.20pm.
A 78-year-old man was also taken to hospital with smoke inhalation but recovered.
Carol's cause of death was "severe burns, inhalation of smoke due to house fire."
An investigation from the fire service discovered a lighter and e-cigarette on her bed.
A second lighter was found on the floor.
It was determined the fire was an "accident in nature as a result of careless disposal and/or use of smokers materials among the smokers clothing or bedding."
The court was told that Carol was not smoking before the fire took place.
An expert's report into Carol's care stated that there was a "considerable likelihood" that she might smoke in bed, and she would have been unable to protect herself in the event of a dropped match or lit cigarette.
Mr Ul-Hassan added: "The expert considered, had these risks been identified, they could have been mitigated appropriately and made sure that she was supervised while she smoked."
A review into the fire alarms in the care home was also conducted and found that the "zone" chart used to identify the location of the activations were inaccurate.
The fiscal depute stated: "However, it cannot be said that the loss of Carol's life was contributed to the delay in attendance to her room."
It was revealed that the Darlington-based company - whose turnover in September 2023 was £398million - has two previous convictions.
In 2019, Kirkcaldy Sheriff Court was told that a resident in a care home with Alzheimer's ingested a chlorine tablet which was among unattended cleaning items that had been delivered. The firm was fined £270,000.
Peter Gray KC, defending, told the court: "Miss Hughes lost her life due to the failings of HC-One.
"I am told to offer my deepest sympathies for the family's tragic loss."
The advocate stated that the company has since taken measures to make sure the incident does not happen again such as a new fire alarm zone map as well has handheld radios for staff communication during an emergency.
Sheriff Matthew Jackson KC stated in his sentencing: "There is nothing this court can do to bring Carol Hughes back - what I can and must do is select an appropriate sentence.
"This is a figure that will remind the company's directors and shareholders, the gravity of the offence.
"I must stress, this is not or can be a figure that represents the terrible loss of Carol Hughes' life."
Speaking after the sentencing, Debbie Carroll, who leads health and safety investigations for the Crown Office and Procurator Fiscal Service (COPFS) said: "The death of Carol Hughes could have been prevented if HC-One Limited had suitably and sufficiently assessed the risks to her health and safety by having access to smoking materials whilst bed-bound.
“Their failure to maintain the fire alarm detection system, ensuring it could accurately identify the location of the activation, led to delay in getting to the fire.
"This prosecution serves to highlight the need for all care homes to protect their residents and remind them they will be held accountable if they fail to do so.”
A spokesperson for HC-One Scotland, said: “First and foremost, we extend our deepest condolences and sincere apologies to the family of Ms Hughes.
"The safety of those in our care is our absolute priority, and we were deeply shocked and saddened by the tragedy that occurred in 2017.
"It was important to us that lessons were learned from this tragic incident, and we have undertaken extensive reviews of our fire management protocols and safety systems across our homes.
"We have also since enhanced our care planning processes and coaching for our teams.
"We are clear that this incident should never have happened, and we hope that today’s decision can bring a sense of closure to Ms Hughes’ family.”
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