A “catalogue of failures” led to the death of two people in wheelchairs after a boat capsized in a Devon lake, marine accident investigators said.
Alison Tilsley, 63, and Alex Wood, 43, Drowned after being thrown from a wheelchair-accessible boatat Roadford Lake, near Okehampton, on 8 June 2022.
In its investigation report The Marine Accident Investigation Branch (MAIB) found South West Lakes Trust (SWLT), which owned the activity center that ran the boat trip, had not maintained the vessel or considered the risks.
Andrew Moll OBE, Chief Inspector of Marine Accidents, said: “On the day no one recognized the implications of carrying vulnerable people who were strapped into heavy motorized wheelchairs around a lake in an open boat.”
Ms Tilsley and Mr Wood were residents of Burdon Grange care home in Beaworthy when they took part in a day trip to the lake.
The MAIB reported that they were strapped into their wheelchairs and were dragged to the bottom of the lake and drowned after the wheelie boat capsized.
The report found water had leaked into the vessel and seals on the bow ramp had degraded which caused the capsize.
This, the MAIB said, was because the wheely boat “had not been properly maintained”.
The investigators recommended SWLT update its maintenance program and employ a permanent member of staff to oversee upkeep at all its activity centers.
They also advised the trust to train staff in disability awareness and ensure instructors know how to evaluate the weight and load distribution when working with wheelchair users and watercraft.
‘No eye on the risks’
The MAIB recommended the care home revises its risk assessments for activities provided by external suppliers.
It advised the Wheelyboat Trust, which owned the vessel, to make sure its owner’s manual included guidance around the securing of wheelchairs and the carriage of heavy, motorized wheelchairs.
Mr Moll OBE, said: “In short, no-one had their eyes on the risk, and tragically Alison Tilsley and Alex Wood lost their lives.
“As well as the catalog of failings highlighted by the report, the investigation has also uncovered a worrying lack of oversight” which he said “must be seen as an impetus for urgent action”.
‘Future considerations’
A spokesperson for The Wheelyboat Trust said it noted that the MAIB did not find the design of the vessel to have contributed to the incident but that it would review the report’s recommendations.
James Platts, chief executive of South West Lakes Trust, said the trust welcomed the report and would implement its “applicable” recommendations.
He said the trust continued to work with activities organizations but had stopped using wheely boats.
“While we immediately ceased the use of wheelyboats on our waters following the incident, we recognize the benefits vessels of this type provide to those with disabilities and will consider the future operation of such vessels in the context of the recommendations,” he said.
The BBC has approached the Burdon Grange care home for comment.