Devon care home fined £200,000 after two residents drowned

Burdon Grange failed to provide safe care

A Devon care home has been fined more than £200,000 after two wheelchair users drowned when a leaking boat capsized during a day trip. 

In June 2022 staff from Burdon Grange Care Home, near Okehampton, 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. 

While on the lake, the Wheelyboat carried three of the people. The boat took on water and capsized, resulting in the deaths of two people, Alison Tilsley and Alex Wood, and serious harm to a third, Kate Dart. 

Burdon Grange Care Home pled guilty to failing to provide safe care and treatment to three people resulting in avoidable harm to them. This resulted in three offences under Regulation 22 (2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.  

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

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. 

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.”