Watch a full report from ITV News Anglia's Rob Setchell.
A mum-of-three who drowned when she fell from a hire boat and became caught in the propeller could have been saved if an adequate guardrail had been fitted, investigators found.
Laura Perry was on holiday on the Norfolk Broads in August 2020 as part of a nine-strong group, along with her partner, who was the nominated skipper, and her three sons, aged 16, 14 and four.
Her mother and father, her sister, who was the driver, and her 16-year-old niece were also in the group on the 12.8-metre motor cruiser Diamond Emblem 1.
The report found she would have been unlikely to have fallen if a better guardrail had been in place. It also made recommendations about improving guidance for people hiring boats, after hearing that the group had been trained in a handover that lasted "about 10 minutes".
Ms Perry fell overboard from the rear deck when the boat’s stern hit the embankment wall opposite Great Yarmouth Yacht Station on the River Bure, a Marine Accident Investigation Branch (MAIB) report said.
It happened on the third day of their five-day holiday, at 1.18pm on 19 August 2020.
"She became entangled in a length of rope and the propeller, suffering multiple injuries that resulted in her drowning," the report said.
"It is likely that Laura would have been prevented from falling into the water if Diamond Emblem 1 had been fitted with an adequate guardrail around its stern.
"The boat’s driver at the upper helm control position was unable to control the motor cruiser at the time, most likely because the helm position changeover lever had been incorrectly set to the lower helm position."
Further contributing factors were identified in the MAIB report, relating to the "technical features of the dual-helm control system".
The investigation found that “both the boat handover and the documentation provided to the family were insufficient to ensure that the hire party were competent to drive a boat with dual-helm control”.
It said that the handover, which took “about 10 minutes”, happened while the group’s luggage was being loaded on to the boat.
In October 2020, the chief inspector of marine accidents urgently recommended a strengthening of requirements for person overboard prevention, handover procedures and engine control systems to the Association of Inland Navigation Authorities.
Further recommendations were made about issues including handover to the owner of the hire boat, and a series of recommendations were made to the Broads Authority.
Chief inspector Andrew Moll said: “Large motor cruisers with sophisticated controls are becoming increasingly common and are often driven by members of the public who have limited or no proficiency in boat handling.
“It is imperative that complex multi-helm controls incorporate appropriate technical features and indications to minimise the likelihood of an inadvertent loss of control.
“Adequate protection around exposed deck areas is equally important in ensuring that no one falls into the water.
“Furthermore, handovers, including in-water demonstrations, and hire boat documentation need to be complete and rigorous in order to ensure that hirers have sufficient proficiency to safely handle the vessel in their charge.
“Following this investigation, I have made recommendations to enhance the governance, oversight and safety of hire boat operations.
“I have also recommended to the boat’s operator that they address various aspects of the safe operation of their boats.
“This includes enhancing its handover procedures and undertaking a thorough assessment of the risks of people falling overboard from its hire craft to ensure that the hazards are appropriately mitigated.
“Such an assessment is essential to ensuring that another similar accident to this does not happen again.”
Hire boat operator Ferry Marina said in a statement: “As this is an ongoing process we are not able to comment at this stage.”
Norfolk Police said at the time that Ms Perry was in her 30s and from London.