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Loss of life was avoidable in the worst mass drowning from a small boat crossing in the Channel, a public inquiry has found.
The 454-page report by the former high court judge Sir Ross Cranston is highly critical of failings around the deaths of at least 24 men, seven women and two children in November 2021, four of whom are still missing.
The inquiry was not able to conclusively determine the number of people on the boat. One of two survivors said there were others onboard, including an Ethiopian man and at least two other young children, who had neither been found nor accounted for. Those on board were given orange lifejackets that appeared to have been stuffed with cotton, which provided ineffective buoyancy.
The Cranston inquiry found that systemic failings, missed opportunities and inadequate resourcing undermined the UK’s maritime search and rescue response on the night of the disaster. HM Coastguard was placed in an “intolerable position”, it said, with chronic staff shortages and limited operational capacity contributing directly to the failure to rescue people in the water.
Calling for an end to small boat crossings, Cranston said on Thursday: “Apart from other reasons it is imperative to prevent further loss of life. Travelling onboard a small, unseaworthy and overcrowded boat and crossing one of the busiest shipping lanes in the world, is an inherently dangerous activity.”
Of coastguard staff shortages and the failure to alleviate them, he said: “This represents a significant, systemic failure on the part of government.
“This is above all an immeasurable human tragedy,” he said.
The report said that some of the deaths could have been prevented. It found people smugglers had supplied an unsafe vessel with inadequate safety equipment and dangerously overloaded it; the French naval vessel Flamant, although closest to the stricken dinghy when a UK mayday call was issued, failed to respond; and there were flaws in HM Coastguard’s search and rescue response, including the premature termination of the search early on 24 November even though survivors remained in the water for hours afterwards.
The inquiry examined why UK Border Force’s HMC Valiant did not leave until 2.22am although it was tasked to respond shortly after 1.30am, following the first distress call at 1.06am. It is estimated that people went into the water at about 3.12am.
Valiant did not find the stricken dinghy, referred to as “incident Charlie”, but 10 minutes later it found another boat it wrongly believed was the vessel and as such the rescue was stood down. Expert evidence concluded as many as 15 victims were likely to have still been alive by sunrise and a some may have survived until early afternoon.
At about 12.30pm, a French fishing boat found the first bodies floating on the water. The report said: “If the Flamant had attended incident Charlie many more and possibly all lives would have been saved.”
The report identifies a number of systemic failings, including chronic understaffing at Dover Maritime Rescue Coordination Centre, a problem that had been repeatedly flagged internally before the mass drowning. A surveillance aircraft that should have provided critical intelligence never launched because of the weather and there was no pre-determined contingency plan. Calls and messages from the small boat were missed or not followed up, including geolocation information sent by WhatsApp.
The report found that there was a widely held belief within HM Coastguard that small boat callers “exaggerated distress”. This led to an underestimation of the emergency and the mistaken belief on the night that the sinking boat had been rescued. It also found ineffective use of interpreting tools such as Language Line.
Two people survived. One, Issa Mohamed Omar, testified to the inquiry that he saw the bodies of 15 victims still clinging to the sunken boat on the morning of 24 November. He recalled a mother screaming, searching for her children.
The 18 recommendations made by the inquiry include HM Coastguard seeking “at pace” to invest in technology to reconcile duplicate small boat incidents, and frequent staff training including the need to avoid bias. The report also called for an external body to regularly assess the effectiveness and efficiency of HM Coastguard.
People smugglers’ actions are subject to continuing investigations in France.
Maria Thomas of Duncan Lewis solicitors, who represents many of the bereaved relatives, welcomed the inquiry’s findings. “Devastatingly, the report concluded that if a search for survivors had been undertaken adequately, more lives would likely have been saved, including those who remain missing.”
The refugee charity Care4Calais says the inquiry must be the watershed moment that ends the “dehumanisation” of refugees seeking sanctuary in the UK.
A senior Home Office source said: “It was important for the inquiry to tell the story of those who died but also of the people from RNLI, coastguard and Home Office, many of whom who went out to sea in dangerous conditions to save lives.
“Although the rescue effort fell short that night, this shouldn’t detract from the huge personal sacrifice made by those involved in dangerous rescues in the Channel to this day and it is positive that their professionalism has been recognised by the chair of the inquiry today.”
