A ‘catalogue of failings’ led to the death of two wheelchair users in a lake after the boat they were enjoying a trip on capsized. The incident saw six people thrown into the water on Roadford Lake in Devon on Wednesday, June 8, 2022, at 1.30pm. Four were rescued, but two people – Alison Tilsley, 63, and Alex Wood, 43 – lost their lives. Both wheelchair users and were residents from Burdon Grange Care Home in Beaworthy who were participating in a day trip on the lake.
A report, published by the Marine Accident Investigation Branch (MAIB), criticised the lack of safety precautions, stating that the wheelyboat which was used had not been correctly maintained, allowing water to leak into the boat and making it unstable. The residents who were strapped into their wheelchairs were dragged to the bottom of the lake and drowned. The bow ramp seals were not subjected to regular inspection before use and had degraded, compromising the watertight integrity of the wheelyboat. The reported added that ‘no one had their eye on the risk’ on the day of the tragedy.
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. In short, no one had their eye on the risk, and tragically Alison Tilsley and Alex Wood lost their lives.”
“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.” Roadford Lake is home to Roadford Lake Activity Centre, operated by the South West Lakes Trust charity. The MAIB investigation concluded the activity centre had not fully identified the risks or understood the unique needs of operating the wheelyboat with wheelchair users.
The key safety issues identified in the report were: the watertight integrity of the bow ramp seal had degraded, the wheelyboat capsized when water accumulated on the deck, the risks of strapping wheelchair users in their chairs were neither considered nor mitigated, both the activity centre and the care home assumed the other had knowledge about managing the activity for disabled people.
The investigation has led to a number of safety recommendations being made to the Local Government Association, South West Lakes Trust, Burdon Grange and The Wheelyboat Trust. The recommendations include updates to maintenance systems, staff training in disability awareness, and revisions to risk assessments for activities involving disabled individuals.
The report has highlighted the need for improved oversight and maintenance procedures to prevent such tragic incidents in the future. These findings serve as a stark reminder of the importance of ensuring safety standards are met in all activities involving vulnerable individuals.