The boat that capsized and killed two wheelchair users was leaking and poorly maintained

An investigation into the tragic deaths of two disabled people on a lake in Devon after a boat capsized has revealed a shocking list of failings and a “worrying lack of oversight”. A report published by the Marine Accident Investigation Branch (MAIB) calls for urgent action and a possible change in the law.

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

Another person was critically injured. The MAIB has confirmed that the two people who lost their lives – Alison Tilsley, 63, and Alex Wood, 43 – were both wheelchair users and were residents of Burdon Grange Care Home in Beaworthy who were taking part in a day trip on the lake.

When the roller boat 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 that the wheelyboat had not been properly maintained, causing water to enter the boat and making it unstable, resulting in the capsizing. The bow ramp seals had not been regularly inspected prior to use and had deteriorated, compromising the watertightness of the wheelyboat.

Roadford Lake is home to the Roadford Lake Activity Centre, run by the South West Lakes Trust charity. The MAIB investigation concluded that the activity center had not fully recognized the risks and understood the special requirements of operating the Wheelyboat with wheelchair users.

The risks of strapping wheelchair users to their chairs had not been “considered or mitigated” and it was noted that both the activity center and the care home assumed the other had knowledge of managing the activity for disabled people.

Andrew Moll OBE, chief maritime casualty inspector, said: “Wheelyboat rides were beneficial to the ongoing wellbeing and therapy of residents at the care home, however no one had taken the time to properly consider the risks associated with taking the wheelchair with them.” Users afloat, either before the accident or on the day itself.

“The condition of the wheelyboat had deteriorated, allowing water to enter, and that day no one realized the impact of transporting vulnerable people strapped into heavy motorized wheelchairs around a lake in an open boat. In short, no.” They had the risk in mind and tragically Alison Tilsley and Alex Wood lost their lives.

“In addition to the catalog of shortcomings highlighted in the report, the investigation also uncovered a worrying lack of oversight that must be seen as an impetus for urgent action. Charitable activities like this seem to fall into a gray area where there is no organization or authority in a supervisory position.

“This meant that no one intervened to question what had become custom and practice. Solving this problem is not easy and may only be possible with a change in the law, but the current situation should not be tolerated.”

The key security issues identified in the report were:

• The watertight integrity of the bow ramp seal had deteriorated

• The wheelyboat capsized when water accumulated on the deck

• The risks of strapping wheelchair users to their chairs were neither considered nor mitigated

• Both the activity center and the care home assumed that the other had knowledge of managing the activity for disabled people.

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

The Local Government Association recommends:

South West Lakes Trust recommends:

• Updating the planned maintenance system of its activity centers to include the specific maintenance tasks required by the manufacturers of the watercraft they operate, including boats used by people with disabilities.

• Hire a permanent employee to take care of the maintenance and condition monitoring of all boats in the leisure center.

• Train and train teaching and support staff on disability awareness through participation in approved disability awareness training courses.

• Ensure activity center instructors are trained to assess weight and load distribution for users of vehicles designed for wheelchair users to ensure compliance with design load and manufacturer instructions.

• Revise driver assessment requirements for vehicles designed for wheelchair users to ensure drivers are able to recognize developing hazardous situations and take emergency action.

Burdon Grange Nursing Home is recommended for:

The Wheelyboat Trust recommends:

• Review the wheelchair boat owner’s manual to ensure that the instructions for securing the wheelchair and transporting heavy, motorized wheelchairs are appropriate.

• Remind operators of wheelyboats delivered under a placement agreement of the need to submit annual condition reports and take steps to ensure that wheelyboats are maintained in accordance with the owner’s instruction manual and Wheelyboat Trust 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 continue to be felt deeply by our community.

“Although the MAIB has completed its investigation, we are mindful of the fact that it is a multi-agency investigation and Devon and Cornwall Police, the Health and Safety Commission and the Care Quality Commission have not yet completed their findings, so we have won.” I will not be making any further comments at this time.

Following the deaths, staff at the Roadford Lake Activity Center were praised for their heroic actions. Roadford Lake Sailing Club said staff helped “minimise the loss”. In a tribute, Alison’s family said they were “completely devastated” at the loss of the “kindest, most caring and loving daughter, sister and aunt”.

They said: “She was loved by everyone who ever met her. We will miss her sunny nature, her positive attitude, her fantastic sense of humor and her skill with words. Our hearts are forever broken, but the messages of love and support we have received have brought great comfort.”