A Birmingham care home has been fined £150,000 after one of its residents was accidentally strangled by the seatbelt of her wheelchair.
Bupa Care Homes Ltd pleaded guilty at Birmingham Crown Court on Tuesday to failing to ensure its residents were not exposed to health and safety risks.
It had previously pleaded guilty to other health and safety breaches at Amberley Court Nursing Home, Edgbaston.
Resident Brigid O'Callaghan, 74, died in the accident in October 2005.
The owner of the home, Bupa Care Homes Ltd, of Horsforth, Leeds, has also been ordered to pay £150,000 in court costs.
The hearing was told how Mrs O'Callaghan had refused help getting into bed and slipped from her wheelchair, causing the lap belt to wrap around her neck.
There were notices warning about the risks of lap belts posted around the home but staff had not been given training into the potential dangers, the court heard on Tuesday.
The prosecution said no-one had checked on her in the night.
Speaking after sentencing on Wednesday, Tim Seal, regional director of Bupa Care Services, said the circumstances of Mrs O'Callaghan's death were "wholly exceptional" and added the incident "should never have happened".
He said it arose because a nurse and carer had not followed Bupas' own care guidelines but it also accepted there were other failings in the way the home was being run in 2005.
Mr Seal said: "Those issues have been addressed and this progress in key areas has been noted during a number of detailed monitoring visits and inspections that have taken place since.
"The HSE and the court also confirmed that whenever we identify any safety issues we do provide the necessary resources to put the problem right."