Devon care provider ordered to pay £200,000 after two residents died on boat trip

A Beaworthy care home has been ordered to pay more than £200,000 by magistrates after a 2022 boating tragedy claimed the lives of two residents and injured a third.

Burdon Grange Care Home Limited pled guilty to failing to provide safe care and treatment to three people resulting in avoidable harm to them at Exeter Magistrates' Court yesterday (Thursday, October 23).

Wheelchair users Alison Tilsley, 63 and Alex Wood, 43, died when a boat designed for wheelchair users overturned at Roadford Lake during a trip organised by the home. A third person, Kate Dart, was injured.

Magistrates fined Burdon Grange Care Home Limited £180,000 and it was also ordered to pay a £190 victim surcharge and £20,000 costs.

The court heard that on June 8, 2022, staff from Burdon Grange took six people, all of whom were wheelchair users, on an outing to Roadford Lake Activity Centre. The group hired a ‘Wheelyboat’ from the centre for a trip on the lake.

Above: Both victims were residents at Burdon Grange Care Home. Credit: Google Street View

While on the lake, the Wheelyboat carried three of the people. The boat took on water and capsized, resulting in the deaths of Ms Tilsley and Mr Wood and serious harm to Ms Dart.

It was stated the provider, manager and staff failed to assess the risks of the boat trip and did not take reasonable, practical steps to manage the risks for the highly vulnerable people in their care.

Staff also failed to plan for what would happen if service users entered the water. One staff member present could not swim.

The court case followed a Care Quality Commission (CQC) investigation. Catherine Campbell, CQC’s deputy director operations in Devon, said: “When people are supported to take part in activities, they have the right to expect providers will properly assess and manage the risks to keep them safe.

“Tragically, this did not happen for Alison Tilsley, Alex Wood and Kate Dart at Roadford Lake.

“The failure of the provider, management and staff to identify and address clear dangers was unacceptable and placed highly vulnerable people at serious risk of harm.

“Most care providers take their responsibilities seriously and act to protect the people they support. But when a provider falls short and puts lives in danger, we will act to hold them accountable.

“This outcome can never reflect the value of the lives lost, but it should remind all providers of their duty to protect people in their care by carrying out thorough risk assessments and taking every reasonable step to keep them safe.”

A statement issued shortly after the court’s verdict by Burdon Grange Care Home Ltd said: “We acknowledge, and have pleaded guilty to, charges brought by the Care Quality Commission (CQC) under the Health and Social Care Act 2008 against Burdon Grange Care Home Limited.

“The charges relate to a boating tragedy at Roadford Lake near Okehampton on June 8, 2022 where devastatingly, two of our beloved residents lost their lives when the boat they were on capsized.  

“We recognise the pain and distress this boating tragedy has caused the families, relatives, and friends of Alex and Ali whose losses are still profoundly felt by our community.

“Our priority now is to move forward and consistently deliver the high-quality care and support our residents and their families rightfully expect.”

An investigation was carried out into the tragedy last year by the Marine Accident Investigation Branch (MAIB), whose report found that South West Lakes Trust (SWLT), which owned the activity centre that ran the boat trip, had not maintained the vessel or considered the risks.

The report stated Ms Tilsley and Mr Wood were strapped into their wheelchairs and drowned after the boat capsized and they were dragged to the bottom of the lake.

The investigation also found that water had leaked into the vessel and seals on the bow ramp had degraded which resulted in capsizing.

This, the MAIB said, was because the Wheelyboat ‘had not been correctly maintained’.

Investigators recommended SWLT update its maintenance programme and employ a permanent staff member to oversee upkeep at all its activity centres.

They also advised the trust to train staff in disability awareness and ensure instructors know how to evaluate weight and load distribution when working with wheelchair users and watercraft.

The MAIB recommended the care home revises its risk assessments for activities provided by external suppliers.

It advised The Wheelyboat Trust, which owned the vessel, to make sure its owner's manual included guidance around the securing of wheelchairs and the carriage of heavy, motorised wheelchairs.