'Changes needed' says report, after two people drown while strapped to wheelchairs on day trip
A Marine Accident Investigation Branch report has made a number of safety recommendations
Last updated 17th Oct 2024
A report's called for a major changes after two people - in wheelchairs - drowned whilst on an organised boat trip in Devon.
The so-called 'wheelyboat' capsized at Roadford Lake in June 2022 whilst on a care home daytrip for adults with disabilities.
The pair, Alex Wood, 43, and Alison Tilsley, 63, has been strapped to their wheelchairs and they were dragged to the bottom of the lake - after the boat capsized - sparking a major emergency service response leading to some people being rescued and taken to Plymouth's Derriford Hospital.
A Marine Accident Investigation Branch report found the part which failed had not been regularly checked along with problems with training, planning and oversight.
Andrew Moll OBE, Chief Inspector 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.”
Activity centre staff praised for heroic actions following Devon lake tragedy
The MAIB investigation found that the wheelyboat 'had not been correctly maintained, allowing water to leak into the boat and making it unstable, which led to its capsize'.
It also warned: "The activity centre had not fully identified the risks or understood the unique needs of operating the wheelyboat with wheelchair users."
The owners of Burdon Grange Care Home said: “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.”
A number of safety recommendations have been made
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.