A care home has been fined £60,000 for failures that led to the death of a pensioner who fell down stairs.
Margaret Young, 83, who had Alzheimer's, was found in the boiler room in Kinning Park Care Home, Glasgow hours after she was reported missing.
She was taken to hospital but died from her injuries two weeks later, a court heard.
The Mair Street care home admitted a charge under the Health and Safety at Work Act.
It was found the boiler room door had a fault and did not lock properly.
It has since been fixed by making sure it "bangs" closed - a procedure which was described as "simple yet effective".
During sentencing on Thursday sheriff Alan MacKenzie said: "On that date the failure of the closing mechanism had tragic consequences."
"In an environment where Margaret Young, at her age and with her particular vulnerabilities, ought to have been safe, it is evident that she experienced a horrific accident which ultimately led to her death."
Mrs Young was reported missing on 28 September, 2015 - at the time there was a small corridor residents could walk along, with a door in it that lead to stairs and a boiler.
It was always kept locked to prevent residents from getting access.
Procurator fiscal depute Lynne Jamieson said Mrs Young's family thought she seemed "agitated" during a visit on the same day she went missing.
At about 16:00 a member of staff saw her walking up and down the ground floor corridor.
Half an hour later the care assistant went to feed Mrs Young and saw she was no longer in the corridor, or in her room.
Staff carried out a search of the home inside and out for about an hour before contacting her family and police.
Officers carried out their own search and found the boiler room door locked - staff told police nobody had been inside all day.
At 20:30 the director decided to check the boiler room - it was unlocked by a key and a "mumbling sound" could be heard.
Mrs Young was found lying at the bottom of a set of stairs with a head wound.
The pensioner was taken to the Queen Elizabeth University Hospital but died on 12 October.
The court heard the door should close itself from any open position.
It was tested three days earlier but it wasn't noticed that when slightly ajar the door did not close automatically.
Mrs Young's family described her as "an incredible mother, grandmother and sister".
A statement, issued through law firm Digby Brown, said: "Families like ours reluctantly put our loved ones into care homes because we genuinely believe it's the best and safest place for them where they will be cared for in a safe, caring and dignified environment.
"So for Margaret to die in the way she did makes it all the more agonising."
Defence counsel Gavin Anderson said the company "apologises unreservedly".
Lawyer David Wilson, who his helping some of her family pursue a civil action against the care home said it was a "tragic and avoidable incident".
- 7 February 2019