Poor maintenance caused a boat carrying wheelchair users to capsize, leading to the deaths of two people, an investigation has found.
Alex Wood, 43, and Alison Tilsley, 63, were on a day trip from a care home when they drowned on Roadford Lake, near Okehampton, Devon, on 8 June, 2022. They were both found the following day.
Four other people were thrown in the water when Wheelyboat 123 - a recreational craft modified for wheelchair users - capsized.
A report by the Marine Accident Investigation Branch (MAIB) found that the boat was not correctly maintained.
Seals on a ramp were not regularly inspected and had degraded, allowing water to leak into the boat and make it unstable. This led to the vehicle capsizing.
The report also found that the two victims were strapped into their motorised wheelchairs and "dragged to the bottom of the lake".
Mr Wood, who was married and from Aylesbury, Buckinghamshire, and Ms Tilsley, known as Ali, were residents at the Burdon Grange care home in nearby Beaworthy.
Chief inspector of marine accidents at MAIB, Andrew Moll, said: "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," Mr Moll said.
"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."
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The MAIB also said Roadford Lake Activity Centre, which hired out the vessel to the care home, had not fully understood the "unique needs" of operating it.
James Platts, chief executive of South West Lakes Trust, which manages the centre, said: "We are reviewing the report thoroughly and will be implementing the applicable recommendations accordingly.
"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," he added.
"Our thoughts remain with those affected by this tragedy, their friends and family."
(c) Sky News 2024: Roadford Lake: Wheelchair users died during day trip from care home when boat capsized
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