Two killed in boat capsize were strapped to wheelchairs and 'dragged' to lakebed

• An investigation has found "no one" considered the risk of taking wheelchair users onto Roadford Lake, as ITV News' Grace Pascoe reports

A "catalogue of failings" lead to the deaths of two care home residents who were strapped into their wheelchairs on a boat trip and dragged to the bottom of a lake when the boat capsized, a report has found.

Alison Tilsley, 63, and Alexander Wood, 43, were "thrown" into the water at Roadford Lake, near Okehampton in West Devon, and sank so rapidly they could not be saved. Their bodies were recovered the following day.

A third resident was pulled from the water not breathing but survived after receiving CPR at the scene before being flown to hospital.

An investigation by the Marine Accident Investigation Branch (MAIB) has now revealed the boat they were on was "poorly maintained" and leaking. It also found "no-one" had considered the risk of taking wheelchair users out onto the water.

The incident happened on 8 June 2022 when staff from Burdon Grange care home took six of its residents for a day trip to the South West Lake Trust activity centre at the lake.

The group was split into two, with the first group made up of two members of care home staff and three residents.

They were all given buoyancy aids and loaded onto the Wheelyboat 123. The vessel was provided by the Wheelyboat Trust - a UK charity that supplies groups and organisations with wheelchair-accessible boats.

But the report says the Wheelyboat 123 was poorly maintained and water leaked on board, causing the boat to capsize.

"The occupants of the boat were thrown into the water during the capsize," the report says.

"The two residents were strapped into their motorised wheelchairs and rapidly sank to the bottom of the lake when they were thrown into the water and could not be rescued."

The report says Ms Tilsley, who had limited motor skills due to a neurological disorder, initially grabbed her carer's hand as they were both dragged below the surface.

But Ms Tilsley's motorised wheelchair weighed 124kg and she let go of the carer's hand before sinking rapidly.

Mr Wood, who had severe and complex care needs due to a blood clot on his brain following a head injury, was similarly dragged down by his wheelchair, which weighed 117kg.

The third resident, who had multiple sclerosis, had been in a manual wheelchair weighing 18kg. They were pulled from the water not breathing by the centre's visitor experience manager. Despite being in a critical condition, they survived after being given CPR and receiving hospital treatment.

The MAIB report says both the activity centre and the care home had "assumed" the other party knew about managing the activity for disabled people. It adds that the risks of strapping the residents into their chairs were "neither considered nor mitigated".

Chief Inspector of Marine Accidents Andrew Moll OBE said the boat trips were "beneficial" for residents but said "no one had taken time to properly consider the risks" associated with taking the wheelchair users on the water - either before the accident or on the day itself.

He added: "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."

In a statement, Burdon Grange Care Home said the deaths of Ms Tilsley and Mr Wood are still "deeply felt" by its community and said its thoughts remain with their loved ones.

It added: "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.”

The South West Lakes Trust said its thoughts also remain with those affected by the "tragedy".

Its chief executive James Platts said the Trust is reviewing the report and will implement its recommendations.

"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," he said.

He added: "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."

In a statement, The Wheelyboat Trust said its "heartfelt sympathies and condolences remain with the families and friends of those who died".

The spokesperson said the charity has worked with the MAIB throughout the investigation, adding: "They did not find that the design of the vessel involved contributed to the incident.

"We will be immediately reviewing the recommendations coming out of the report to ensure that our guidance and processes are updated to reflect any changes required.

"As there are still ongoing investigations by the authorities, it would not be appropriate for us to comment further at this time."

Burdon Grange has been approached for comment.