A UK inquiry into the deadliest English Channel crossing on record has concluded some of the 31 victims could have been saved in the tragedy, but instead drowned over the course of a whole day while they waited for rescue.
Although people smugglers who provided a “wholly unsuitable and ill-equipped” boat were to blame for the migrants getting into trouble, the independent probe found that “systemic failures, missed opportunities” and “chronic staff shortages” in the UK’s maritime response contributed directly to the failure to rescue people. A criminal investigation in France is exploring other possible failures there.
The tragedy occurred when a crowded inflatable boat capsized overnight on November 23 into November 24, 2021, leaving just two survivors who were discovered in French waters nearly 12 hours after the first calls for help.
The inquiry, led by Sir Ross Cranston, has identified 27 men, women and children among the dead, while four people are still missing. “Some of those deaths were avoidable,” it said.
Sir Ross said the practice of small boat crossings “must end”.
“Apart from other reasons, it is imperative to prevent further loss of life,” he added.
Home Office figures show 157,058 people have arrived in the UK after making the dangerous journey by small boat between November 24, 2021 and February 3 this year.
In its final report published on Thursday, the inquiry set out three key reasons some of the deaths were avoidable, including how people smugglers provided an “unsuitable” craft which they crowded with at least 33 people.
A French Navy vessel, which was closest to the boat, failed to respond to a mayday message, further delaying the search.
Why the Flamant boat did not act is at the centre of the criminal investigation in France.
French police initially said the crew denied having received the message, but HM Coastguard radio recordings show the ship was using the same channel.
Meanwhile, the UK coastguard made a “number of flawed decisions” for the search and rescue operation into the incident known as “Charlie”, which led to it being ended early on November 24 because of what was described as “failures in record keeping”.
There was also a “widely held belief” within the coastguard that callers from small boats “exaggerated their level of distress”, the report said.
“If the search had continued throughout that day, some of the deaths would have been avoided,” it added.
“These members of the HM Coastguard were placed in an intolerable position because of chronic staff shortages at Dover and other deficiencies. These were known about for some time, but no effective action had been taken to alleviate them.
“This represents a significant, systemic failure on the part of government.”
One of the victims was believed to have died just 30 minutes before rescue, the inquiry was told.
In hearings over four weeks in March last year, the inquiry was told how the boat left the French coast shortly after 10pm on November 23 and about three hours into the journey became “swamped”.
The inquiry’s counsel, Rory Phillips KC, gave details of several distress calls made from the boat to authorities, but the incident was mistakenly marked as resolved and “no one came to their rescue”.
Several calls were made by Kurdish boy Mubin Rizghar Hussein, 16, who was known to have died that night alongside his mother and two sisters.
The report said that between 3.17am – when what was probably the last call from Charlie ended – and 3.33am – the time a WhatsApp message was sent by HM Coastguard to Charlie, which was never delivered – all of the passengers on board the dinghy went fully into the water.
Issa Mohamed Omar, one of the two survivors of the tragedy who gave evidence during the hearings, described how he kept moving to survive the cold water.
“In the morning I would say around 10 people were still alive,” he said. “It’s a harrowing experience and I just don’t want to remember.
“All night I was holding to what remained of the boat, in the morning I could hear people screaming, it’s something I cannot forget in my mind.”
Cold water expert Prof Michael Tipton concluded that while some of those on board may have drowned immediately, it is likely the majority of victims died over a long period, by sunrise at 7am and between sunrise and the rescue in the afternoon the next day, the report said.
During inquiry hearings last year, many families of the dead and missing paid tribute to their loved ones.
Rasul Farkha Hussein said he hoped the inquiry would find his missing son, Pshtiwan Rasul Farkha Hussein, who he was certain was still alive.
“He was in cold water surrounded by dead people for so long it may be the case that he has lost his mind and does not know that he should call his parents,” he said.
“If someone finds him and he contacts us, our lives would be saved and filled with joy.”
The Home Office’s former director of Clandestine Channel Threat Command, Dan O’Mahoney, told the inquiry that since the incident, aerial surveillance that can operate in adverse weather had been put in place. If the circumstances of that night happened again, “the outcome would have been different”, he said.
The inquiry’s report found that “much has improved” since November 2021 in terms of staff and assets for HM Coastguard, but set out 18 recommendations relating to rescue operations for small boat crossings and mass casualties generally, as well as addressing structural issues for UK organisations related to maritime search and rescue.
