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A specialist care home in Devon has been fined £180,000 for catastrophic failures relating to a boating tragedy which claimed the lives of two vulnerable people. Wheelchair users Alison Tilsley, 63, and Alex Wood, 43, lost their lives when a specially designed vessel capsized at Roadford Lake on Wednesday, June 8, 2022.
Both were residents at Burdon Grange Care Home in Highampton, which had arranged the activity, but had not carried out a proper risk assessment. A court in Exeter heard the risks to those taking part in the trip were 'patently obvious'.
Six people were thrown into the water. Four were rescued, including Kate Dart, another vulnerable service user, who was airlifted to hospital.
Burdon Grange Care Home Limited admitted three breaches of the Health and Social Care Act 2006. The company pleaded guilty to failing to provide proper and safe care to service users resulting in avoidable harm.
District Judge Stuart Smith said: "This case is nothing short of devastating, harrowing and absolutely tragic. He said the lives of two vulnerable and much-loved residents were lost while a third person narrowly escaped death in the most horrific and appalling circumstances, adding there had been a failure to assess, audit, mitigate and manage a risk assessment of a regulated activity.
He imposed a fine of £180,000 and ordered the company pay £20,000 costs. He said the amount would have been higher but he did not want the fine to impact the care of vulnerable people who still live at Burton Grange. The company has a £2.5m annual turnover and employs 88 people with yearly profits of around £300,000.
The court was told the home had previously organised 21 trips on the lake but the tragedy was the first time since the pandemic.
Alison Tilsley and Alex Wood were strapped into heavy electric wheelchairs with no ready means of release or rescue in the event they ended up in the water.
Some buoyancy aids were provided as opposed to life jackets and they were not suitable if people ended up in the water. Three members of staff were present on the boat but one of those could not swim.
The boat capsized after taking on water while returning to shore. Alison Tilsley and Alex Wood were immediately dragged beneath the water by the weight of their wheelchairs. Kate Dart was recovered from the water face down some time later.
The home told police it did not prepare any risk assessment for the trip and thought it was done by South West Lakes Trust which rented out the boat. Judge Smith said this 'overreliance' on others carrying out the risk assessment was a clear oversight.
Judge Smith said the risks were 'patently obvious' - vulnerable users, strapped into heavy wheelchairs with no ability to free themselves, placed in the open water with staff unable to help.
He said the circumstances placed those on the boat in 'grave danger' in the event of it capsizing.
"The company had no idea what risk assessment was in place," he said. There was a 'systemic failure' of health and safety and no audit over a long period of time. The company 'fell far short of the appropriate standards and failing to put in place a meaningful risk assessment', said the judge.
He said no fine he could impose would make up for the loss to the families and the distress caused.
Tamsyn Wood, the wife of father-of-four Alex, said the family's world had been 'blown apart' by his death. She said: "It's like my soul flew off to try to find him and has never returned."
In mitigation, the home said it was 'heartbroken' at the deaths of people it cared about deeply. It was said Burdon Grange had good health and safety and excellent CQC records.
In a statement released afterwards it 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."
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