Burdon Grange Care Home in Beaworthy, in the English county of Devon, has been ordered to pay more than £200,000 after two wheelchair users drowned and a third was seriously injured during a day trip to Roadford Lake on 8 June 2022.
The home admitted three charges of failing to provide safe care under health and social care laws, before taking six residents on the outing. It was fined £180,000, with £20,000 costs and a £190 victim surcharge.
The group used a specially designed “Wheelyboat” to take the group onto the lake, but it took on water and capsized, trapping occupants in heavy electric chairs. Alex Wood, 43, and Alison Tilsley, 63, both died, and their bodies were recovered two days later. A third care home resident, Kate Dart, survived but suffered serious injuries, having been found face down in the water. One staff member, unable to swim, became trapped under the boat for 15 minutes.
District Judge Stuart Smith described the incident as “nothing short of devastating, harrowing and absolutely tragic,” pointing to the home’s overreliance on the boat hirers for safety checks and its complacency about risk. He noted the victims were strapped into wheelchairs with no way to escape and that no lifejacket could have supported Wood’s weight. The court heard that the risks were “patently obvious” and criticised the home for failing to assess and manage the dangers involved.
Wood, a father of four, had been left wheelchair-bound following a rugby accident in France in 2011. His wife Tamsin told the court: “Alex’s death has broken me. I feel cheated. I wanted to make Alex better and bring him home. That has been taken away. I loved Alex so much.” His father, Peter, said the family was “deeply troubled and hurt that his death could have been avoided.”
Tilsley’s family said: “Her sunny nature, positivity, fantastic sense of humour and skill with words will be greatly missed. Our hearts are broken forever but the messages of love and support we have received are of great comfort.”
The court heard that the home assumed South West Lakes Trust, which rented the boats, carried out risk assessments, a belief that proved incorrect. Staff did not plan for emergencies, and some precautions, such as buoyancy aids, were inadequate for wheelchair users.
The home has an annual turnover of £2.5m, employs 88 staff, and has yearly profits of around £300,000. Judge Smith noted the fine was moderated to avoid affecting care for current residents.
Catherine Campbell, deputy director of the Care Quality Commission in Devon, said: “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.”
Burdon Grange said: “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 by the Marine Accident Investigation Branch found the boat had not been properly maintained, with degraded seals allowing water to enter and destabilise the vessel.
The MAIB report recommended that South West Lakes Trust improve maintenance, appoint a permanent staff member for oversight, provide disability training, and ensure instructors can evaluate weight and load distribution with wheelchair users. The trust was also advised to update risk assessments, and The Wheelyboat Trust was told to include guidance in the owner’s manual regarding securing wheelchairs and carrying heavy motorised chairs.
In response to the accident, The Wheelyboat Trust issued a safety notice to all operators about the need for proper maintenance and warning of the dangers of water accumulation.
The judge noted the care home generally provided a safe environment, but that systems were not effectively applied for this outdoor activity, representing a systemic failure in risk management.
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