A report into the deaths of two disabled people who perished when a boat capsized on Roadford Lake in West Devon has strongly criticised the craft’s operators the South West Lakes Trust (SWLT) for safety failures.

Alex Wood, 43, and Alison Tilsley, 63, drowned when the wheelyboat boat on which they were passengers during a day out capsized on June 8, 2022.

They were strapped into their wheelchairs on board and dragged down to the bottom of the lake.

The Marine Accident Investigation Branch (MAIB) report 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.

Crucially, both the activity centre and the care home where the residents lived – Burdon Grange at Highampton – assumed the other was overseeing the safety implications of the boat trip for disabled people, the report said.

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.”

The MAIB recommended that the South West Lakes Trust employ a dedicated member of staff for maintaining boats at its activity centres. It also called for training on disability awareness, a programme of maintenance of watercraft according to manufacturer’s requirements and specific staff training on proper use of boats carrying wheelchair users.

James Platts, chief executive of South West Lakes Trust, said: “We welcome the publication of this report and recognise that its aim is not to assign blame or liability, but to improve water safety and ensure, as far as possible, that future accidents are prevented.

 “We are reviewing the report thoroughly and will be implementing the applicable recommendations accordingly.

 “We continue to operate our other activities under the accreditation of the Royal Yachting Association and the Adventure Activities Licensing Authority. Whilst we immediately ceased the use of wheelyboats on our waters following the incident, we recognise 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.

“It would be inappropriate for us to comment further while other investigations continue. Our thoughts remain with those affected by this tragedy, their friends and family.”

Burdon Grange nursing home was asked to revise its risk assessments for activities provided by others.

A statement from Burdon Grange 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.”