The owner of a nursery was fined #12,500 today after a seven-month-old baby died on her premises.
Dawn Wilson, 45, previously pleaded guilty to one count of failing to discharge a duty as an employer under the Health and Safety at Work Act and was ordered to pay costs of #10,000.
She was sentenced following the death of Cameron Lindsay, whose head became wedged between the hood and seat of a carry chair he was left unattended in for at least 20 minutes while at Sticky Fingers Day Nursery in Bromsgrove, Worcestershire, in March 2004.
He was taken to Birmingham Children's Hospital suffering severe brain damage and died the following day. The cause of death was given as asphyxiation.
Sentencing Wilson, who was cleared of the manslaughter of Cameron at an earlier hearing, Judge David Matthews said he did not think the defendant had breached the law to cut corners and increase profits.
The judge, sitting at Hereford Crown Court, told Wilson: "I am entirely satisfied that you fell short of the required standard to ensure the health and safety of that child.
"That failure, as you know, had the most awful consequences.
"The fine reflects my view that the failings which gave rise to this tragic accident stemmed from well-intentioned amateurism on your part.
"I am aware that the sentence I pass on you will not be regarded as those who've lost someone very dear to them as remotely appropriate or adequate to reflect their feelings."
Wilson, of Plymouth Road, Barnt Green, Worcestershire, remained motionless throughout sentencing.
Philip Parker QC, prosecuting, listed a catalogue of failings at the nursery, which passed its Ofsted inspection the month before, which he said led to Cameron's death.
The lawyer told the court that Wilson had bought the Rock 'n' Carry chair, which bore the British Standards Institution kitemark, after staff said they needed something to feed the babies in.
He said workers had assembled it incorrectly, with the material section of the seat left free from a metal tube it was supposed to be attached to, giving Cameron greater freedom to move about, and failed to read the instructions which stipulated that no child should be left unattended while sitting in it.
The lawyer said a 19-year-old woman who was unqualified to be left in charge of children was given responsibility for the nursery that day as Wilson and her manager were on days off.
Mr Parker said Cameron had arrived at the nursery with his five-year-old brother, Alistair, and was rocked to sleep in the chair, which had no protective barriers and no over-the-shoulder harness to stop him falling out, in the sleeping room.
He had been left alone while staff played outside with children in the garden where the youngster's cries could not be heard. It was 20 minutes later before anyone checked on him.
Mr Parker said: "As far as one can tell, he must have, in that time, wriggled his way up in the chair, his head trapped over the top of the chair, between the hood and the chair itself.
"He then - the chair being relatively unstable - must have flipped over himself, almost a backward somersault, and trapped his neck between the chair itself and the hood, which would have closed as his body went backwards and he was asphyxiated.
"He was used to crying on waking and the movement of the chair showed it would not have been an entirely silent event."
He added: "Proper systems were not in place to ensure Cameron was safe. The set-up was so lax it was inevitable a child would be left unsupervised."
Mark Wall, defending, said his client expressed genuine remorse for the death of Cameron and extended her sympathies to his family.
He said the mother of three had not been able to discuss the events of that day with him because of the distress it had caused her, and said the tragedy had resulted not because of a lack of interest in health and safety but because she had not fully understood the extent of her duties in that regard.
Mr Wall said: "You are not dealing with somebody who has cynically attempted to avoid complying with regulations to line their own pockets, you are dealing with a fully committed woman who wanted to make both a safe and pleasant environment for the children in her care."
Speaking outside court, Cameron's parents, Debra and Christopher Lindsay, said they felt their son's death had been an accident waiting to happen.
Reading from a prepared statement, Mr Lindsay told reporters: "We had entrusted Cameron to the care of a nursery which sold itself on its high standards of care and professionalism and whose latest Ofsted report was good, a report which we subsequently felt merely scratched the surface.
"There were fundamental failings in the management of the nursery. This included a lack of risk assessment and training and allowing an untrained and inadequately qualified 19-year-old girl to manage the nursery.
"In hindsight, we feel the culmination of these failings was an accident waiting to happen."
Mr Lindsay continued: "All we've asked for is justice for our baby boy. And whilst today's verdict does provide some justice, it does little to take away our pain.
"We can only hope the guilty verdict sends out a clear message to all organisations about the severe consequences of failing to provide health and safety legislation."
Wilson and two members of the nursery's staff - Nicola Hadlington, 29, and 21-year-old Rebecca Lamare - were acquitted of manslaughter last October after the prosecution told Worcester Crown Court there was insufficient evidence to proceed with the charge.
Hadlington, of Impney Green, Droitwich, and Lamare, of Houseman Close, Bromsgrove, were not charged with health and safety offences and walked free from court at the earlier hearing.
In a statement released later by West Mercia Police, Acting Detective Chief Inspector Paul Williamson said he hoped today's hearing prompted people who worked with children to review their procedures.
He said: "Our investigation into this incident has been long and thorough and, while we welcome today's decision, we know that it will be little compensation to Cameron's family.
"We have been hugely impressed with their dignity in the face of the immense pain and pressure they have been under, and they can be proud that they have done all that they can to ensure no-one else endures the loss of a child in similar circumstances."
Mr Williamson continued: "It is important that such incidents are fully investigated so that everything possible can be done to minimise the risk of this happening elsewhere, and we hope that today's decision prompts everyone involved in the care and safety of young children to have a close look at their procedures and the equipment they are using."