A care home company has been fined £80,000 after the death of a patient as a result of "inappropriate and dangerous" restraint techniques.
Anthony Pinder, 42, who had learning and behavioural issues, was restrained by staff for about 90 minutes at the Old Vicarage nursing home in Grimsby.
He was released and went to his room but was found dead a short time later.
Health and Care Services (UK) Ltd, part of the Cragmoor Group, admitted a health and safety at work charge.
The company was also ordered to pay £40,823 in costs.
The Health and Safety Executive (HSE), which brought the prosecution, told Leeds Crown Court that the company failed to ensure staff were adequately trained to carry out the safe physical restraint of residents.
It said the measures used to control Mr Pinder were described as "poor, inappropriate and dangerous" during the case.
It said those involved in the restraint were not blamed because the court heard they were doing what they thought was necessary under difficult circumstances.
The HSE said the Commission for Social Care Inspectorate had highlighted an urgent need for safe restraint training five months before Mr Pinder's death.
This prompted a written promise from senior management at the company that improvements would be made.
However, the investigation found that no such training was given.
The company pleaded guilty to failing to take all reasonably practicable steps to protect patients at the Old Vicarage - a breach of the Health and Safety at Work Act.
HSE Inspector Brian Fotheringham said: "Anthony Pinder was a vulnerable person whose death was entirely avoidable...
"Senior management knew staff at the Old Vicarage often had to physically intervene and restrain residents, but they failed to ensure staff were trained in appropriate and safe restraint techniques."
He added: "The company says that steps have been taken to prevent a repeat of this incident.
"I hope Anthony's tragic and untimely death and the subsequent prosecution, sends an important message to all care sector companies."