'Enormous human error' in Margaret Gilchrist bath death
The death of a vulnerable woman in a bath at her home was a "preventable" accident, a sheriff has concluded.
Margaret Gilchrist, 50, died at her home in Glasgow in September 2013 after being scalded on up to 90% of her body.
A fatal accident inquiry found that her death could have been avoided if a carer had not left the hot tap running and had checked on her more regularly.
Sheriff Lindsay Wood said Enable Scotland worker Mary Cameron had made an "enormous human error".
Ms Gilchrist, who had severe learning difficulties from birth and was registered blind and had epilepsy, was cared for full-time at her home in Carntyne.
She died after an incident on 26 September 2013, with a fatal accident inquiry carried out between November 2015 and September 2016.
In his determination, Sheriff Wood described what happened as "an accident which was entirely preventable". He said Ms Gilchrist should not have died in the "manner she did".
His written judgement 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 and the temperature became increasingly excessive as the TMV (thermostatic mixing valve) did not function properly.
"Consequently, Margaret was scalded by the hot water and thereafter died.
"Between 80 to 90 per cent of her body had been scalded as, unfortunately, she had been left in the bath longer than usual...certainly in excess of 30 minutes.
"If she had been checked regularly, Mary Cameron may well have seen the distress being caused and might have been able to do something."
He added "visual checks" every three minutes or less could have stopped the accident happening.
'Dignity and humility'
The sheriff said the carer had "committed an enormous human error" adding: "Such is the magnitude, she will require to live with it for the rest of her life."
He accepted it had also been a "traumatic and hugely difficult time" for her as well. Ms Cameron has had her employment terminated by Enable Scotland.
The inquiry also found that there was not a "sufficiently detailed risk assessment" in respect of bathing Ms Gilchrist.
It emerged that if a vital thermostat valve had been replaced with a newer model, then this may have prevented a malfunction and the water becoming scalding.
Also highlighted were "budgetary constraints" which led to less "one-to-one care and supervision". But Sheriff Wood said that of itself did not lead to or cause the death.
He concluded his determination by paying tribute to the "dignity and humility" shown by Margaret's family, who sat in court listening to the distressing details of her death.
The sheriff said they had shown "unfailing dedication" in "serving Margaret's interests".