A “catalogue of failures” led to the death of two people in wheelchairs after a boat capsized in a Devon lake, marine accident investigators said.

Alison Tilsley, 63, and Alex Wood, 43, drowned after being thrown from a wheelchair-accessible boat, at Roadford Lake, near Okehampton, on 8 June 2022.

In its investigation report the Marine Accident Investigation Branch (MAIB) found South West Lakes Trust (SWLT), which owned the activity centre that ran the boat trip, had not maintained the vessel or considered the risks.

Andrew Moll OBE, Chief Inspector of Marine Accidents, said: “On the day no-one recognised the implications of carrying vulnerable people who were strapped into heavy motorised wheelchairs around a lake in an open boat.”

Ms Tilsley and Mr Wood, who was from Aylesbury in Buckinghamshire, were residents of Burdon Grange care home in Beaworthy when they took part in a day trip to the lake.

The MAIB reported they were strapped into their wheelchairs and were dragged to the bottom of the lake and drowned after the wheelyboat capsized.

The report found water had leaked into the vessel and seals on the bow ramp had degraded which resulted in the capsize.

This, the MAIB said, was because the wheelyboat “had not been correctly maintained”.

The investigators recommended SWLT update its maintenance programme and employ a permanent member of staff 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 the 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.

Mr Moll OBE, said: “In short, no-one had their eye on the risk, and tragically Alison Tilsley and Alex Wood lost their lives.

“As well as the catalogue of failings highlighted by the report, the investigation has also uncovered a worrying lack of oversight” which he said “must be seen as an impetus for urgent action”.

A spokesperson for The Wheelyboat Trust said it noted the MAIB did not find the design of the vessel to have contributed to the incident but that it would review the report’s recommendations.

James Platts, chief executive of South West Lakes Trust, said the trust welcomed the report and would implement its “applicable” recommendations.

He said the trust continued to work with activities organisations but had stopped using wheelyboats.

“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 said.

The BBC has approached the Burdon Grange care home for comment.

Follow BBC Devon on X (formerly Twitter), Facebook and Instagram. Send your story ideas to spotlight@bbc.co.uk.