A catalogue of errors led to a "vulnerable" pensioner dying after he was scalded in a bath of boiling water at a respite centre for the mentally ill in Birmingham, a court has heard.
George Inwood, aged 68, suffered burns to 25 per cent of his body two days after being admitted to the home in Yardley Fields Road, Stechford.
Birmingham and Solihull Mental Health Trust, which owned the centre, admitted a charge under the Health and Safety at Work Act.
Deputy District Judge Graham Bennett, sitting at magistrates' court, said: "The evidence in this case shows, in my judgment, a series of errors which amounts to a serious breach of duty."
He said these included:
* The absence of a building risk assessment;
* Having a hot water system that was set on a temperature for boiling;
* Inadequate risk assessment of the physical needs of users of the centre.
Judge Bennett said although it was one of many properties owned by the trust it had inexplicably "gone off the radar."
He ruled that the trust should be committed for sentence on June 2 at Birmingham Crown Court.
Barry Berlin, prosecuting for Birmingham City Council, said Mr Inwood had had dealings with the psychiatric services since 1982, suffered from manic depression and in 2002 had been diagnosed as having Parkinson's Disease.
He had difficulties getting out of bed, getting in and out of the bath and on occasions with using the toilet, and that his wife had assisted him with these functions until she had committed suicide in 2003.
Mr Berlin said Mr Inwood had twice previously been admitted to the centre, a large detached property on three floors. The final time was on March 30 2004, the anniversary of his wife's death.
On the morning of April 1 one of the staff at the centre heard Mr Inwood cry out for help and when she ran to the bathroom discovered the door had been locked from the inside.
Mr Berlin said she could feel the heat from the bathroom door and the paramedic who arrived kicked the door down and found Mr Inwood in the bath with the hot tap still running.
A post mortem revealed the pensioner had suffered extensive burns and that he had a pre-existing heart disease.
Mr Berlin said several staff members had mentioned how hot the water was at the centre but nothing had been done, and although the bath had been fitted with a thermostat mixing valve it was set at the maximum setting
"Had it been set at the right temperature arguably this dreadful incident would never have occurred," he said. "Mr Inwood was exposed to risk. He was a vulnerable man. He was there on the anniversary of his wife's death.
"He went into an open bathroom and it seems he simply got in the bath and switched on the hot water tap that came out boiling and this was preventable."
Bernard Thorogood, defending, said the errors made had been identified and had been made good.
He said the trust had more than 100 sites around Birmingham and Solihull, a workforce of about 4,000 and was one of the largest and most complex in the country.
He added that although Mr Inwood could be described as vulnerable, the word had different shades of meaning and he was capable of looking after himself and would go home on a daily basis and feed his pet.