Boat which capsized killing two wheelchair users was leaking and poorly maintained

It is a shocking and damning report

An investigation into the tragic deaths of two disabled people at a Devon lake after a boat capsized has revealed a shocking catalogue of failings and a 'worrying lack of oversight'. A report, published by the Marine Accident Investigation Branch (MAIB), has called for urgent action to be taken and a possible change in law.

A huge search operation was launched when six people were thrown into the water on Roadford Lake in Dartmoor on Wednesday, June 8, 2022, at 1.30pm, and two remained missing. Their bodies were discovered the following day.

One other person was critically injured. The MAIB has confirmed the two people who lost their lives - Alison Tilsley, 63, and Alex Wood, 43 - were both wheelchair users and were residents from Burdon Grange Care Home in Beaworthy who were participating in a day trip on the lake.

When the wheelyboat they were on capsized, the residents who were strapped into their wheelchairs were dragged to the bottom of the lake and drowned.

The MAIB investigation found the wheelyboat had not been correctly maintained, allowing water to leak into the boat and making it unstable, which led to its capsize. The bow ramp seals were not subjected to regular inspection before use and had degraded, compromising the watertight integrity of the wheelyboat.

Roadford Lake is home to Roadford Lake Activity Centre, operated by the South West Lakes Trust charity. The MAIB investigation concluded the activity centre had not fully identified the risks or understood the unique needs of operating the wheelyboat with wheelchair users.

The risks of strapping wheelchair users in their chairs were said to be neither 'considered nor mitigated', and it was noted both the activity centre and the care home assumed the other had knowledge about managing the activity for disabled people.

Andrew Moll OBE, chief onspector of Marine Accidents, said: "Trips on the wheelyboat were beneficial for the continuing wellbeing and therapy of the residents of the care home, however, no one had taken time to properly consider the risks associated with taking the wheelchair users afloat, either before the accident or on the day itself.

"The condition of the wheelyboat had been allowed to deteriorate so water could enter it, and on the day, no one recognised the implications of carrying vulnerable people who were strapped into heavy motorised wheelchairs around a lake in an open boat. In short, no one had their eye on the risk, and tragically Alison Tilsley and Alex Wood lost their lives.

"As well as the catalogue of failings highlighted by the report, the investigation has also uncovered a worrying lack of oversight which must be seen as an impetus for urgent action. Charitable activities such as this seem to fall into a grey zone with no organisation or authority in a position of oversight.

"This meant that no one stepped in to question what had become custom and practice. Addressing this is not simple and may only be possible with a change in the law, however, the current situation is not something that should be tolerated."

The key safety issues identified in the report were:

• the watertight integrity of the bow ramp seal had degraded
• the wheelyboat capsized when water accumulated on the deck
• the risks of strapping wheelchair users in their chairs were neither considered nor mitigated
• both the activity centre and the care home assumed the other had knowledge about managing the activity for disabled people.

The investigation has led to a number of safety recommendations being made to the Local Government Association, South West Lakes Trust, Burdon Grange and The Wheelyboat Trust. The recommendations in full were:

The Local Government Association is recommended to:

• Bring the report and safety issues to the attention of local authorities and to consider the role of local government in overseeing waterborne charitable activities.

South West Lakes Trust is recommended to:

• Update the planned maintenance system used by its activity centres to include the specific maintenance tasks required by the manufacturers of the watercraft they operate, including boats used by disabled people.
• Employ a permanent member of staff dedicated to the maintenance and condition monitoring of all activity centre craft.
• Train and educate instructing staff and any support staff in disability awareness through the attendance of recognised disability awareness training.
• Ensure instructors at its activity centres are educated in how to evaluate the weight and load distribution for users of craft designed for wheelchair users to ensure compliance with the design loading and manufacturer’s instruction.
• Revise driver assessment requirements for craft designed for wheelchair users to ensure drivers are equipped to recognise developing dangerous situations and take emergency action.

Burdon Grange care home is recommended to:

• Revise its risk assessments for activities provided by organisations outside of the care home environment to identify any hazards faced by the residents taking part in that activity and take steps to assure itself that appropriate risk mitigation measures are in place.

The Wheelyboat Trust is recommended to:

• Review the wheelyboat owner’s manual to ensure that guidance around wheelchair securing and the carriage of heavy, motorised wheelchairs is appropriate.
• Remind operators of wheelyboats supplied under a placement agreement of the need to submit annual condition notes and take action to ensure wheelyboats are being maintained in line with the owner’s manual and The Wheelyboat Trust’s requirements.

Following the conclusion of the investigation, the owners of Burdon Grange Care Home said: “The MAIB has today, October 17, published its findings into the tragedy at Roadford Lake near Okehampton, Devon. Devastatingly, two of our residents lost their lives when the boat they were on capsized on Wednesday, June 8, 2022.

"Our thoughts remain with the families, relatives, and friends of Alex Wood, 43, and Alison Tilsley, 63, whose losses are still deeply felt by our community.

"Although the MAIB has concluded its investigation, we are mindful of the fact that this is a multi-agency investigation and Devon and Cornwall Police, The Health and Safety Commission, and the Care Quality Commission have yet to conclude their findings, so we won’t be commenting further at this time."

Following the deaths, staff at Roadford Lake Activity Centre were praised for their heroic actions. Roadford Lake Sailing Club said staff helped to "minimise the loss". In a tribute, the family of Alison said were "totally devastated" by the loss of the "most kind, caring and loving daughter, sister and auntie".

They said: "She was loved by everyone who ever met her. Her sunny nature, positivity, fantastic sense of humour and skill with words will be greatly missed. Our hearts are broken forever but the messages of love and support we have received are of great comfort."