A coroner said he will write to the Secretary of State for Transport to call for an overhaul of regulations of high-speed thrill rides following the inquest into the death of 15-year-old Emily Lewis.
She died after a speedboat she was on crashed into a navigation buoy.
Captain Emma Tiller, MAIB investigator, said the speedboat crashed after crossing the wake of Red Funnel's Red Falcon five times and had involved making close passes of buoys.
It was shortly after the fifth pass of the Isle of Wight ferry that the rigid inflatable boat Seadogz crashed into the North West Netley buoy at a speed of 38.4 knots.
Emily Lewis suffered fatal injuries after the Rib collided with the 4.5m high buoy in Southampton Water on August 22, 2020, with other passengers seriously injured.
A post-mortem examination found she died as a result of upper abdominal injuries caused by her being thrown forward from the bench seat she was sitting on when the Rib collided with the buoy.
At the Winchester inquest, assistant coroner Henry Charles recorded a narrative conclusion which highlighted issues raised by the Marine Accident Investigation Branch (MAIB) in its investigation.
The coroner pointed to the lack of visibility for the skipper from the helm which was based at the rear of the craft and the fact that the skipper was operating the Rib alone without an additional crew member to keep watch.
He said this went against the recommendations of the Small Commercial Vessels (SCV) Code.
Other issues highlighted included inappropriate seating and handholds used on the Rib to help passengers brace and avoid injury as well as the risk assessment carried out by the company which Mr Charles described as “cursory and generic”.
The inquest heard that Seadogz had been involved in three previous similar accidents from which Mr Charles said lessons had not been learned and quoting the MAIB.
He added that the events of August 22, 2020, were “an accident waiting to happen”.
Mr Charles said there was a “patchwork” of regulations for the maritime industry that was “complex and subject to interpretation”.
He explained that for his report to prevent future deaths, he would be writing to the Maritime and Coastguard Agency (MCA) and the Secretary of State for Transport and other regulatory agencies.
Mr Charles said the MAIB had raised concerns that the sector lacked “appropriate standards and oversight” despite previous fatal incidents.
He said: “It is perhaps startling that it is not until next year that a consultation document to review the SCV regulations will be issued with no clear evidence on when it will be concluded and regulations revised.
“That leaves the MAIB recommendations unanswered and not implemented.”
Dominique Smith, counsel for Emily’s family, had urged the coroner to return a conclusion of unlawful killing.
She said: “We say the skipper’s conduct falls squarely into the realms of jaw-dropping, exceptionally bad negligence from the start of Emily’s journey on the Rib that day to the end.”
Michael Lawrence, 55, who was driving the boat, was found not guilty of manslaughter by gross negligence, but guilty of failing to maintain a proper lookout and failing to proceed at a safe speed.
Michael Howley, 52, the owner of the now defunct Seadogz which ran the boat trips, was convicted of not operating the boat safely.
They were both sentenced at Winchester Crown Court in March 2023 to 18 weeks in custody suspended for two years, ordered to complete 125 hours of community service and pay £1,000 of court costs.
Emily’s parents, Simon and Nikki, and sister Amy, said in a statement after the hearing: “We are disappointed that the coroner did not come to a conclusion of unlawful killing but we appreciate his narrative describes the appalling events in great detail.
“Mr Lawrence has never truly faced justice for his actions and once again he has failed to properly accept and acknowledge his role in the death of our beloved daughter, Emily.
“We are, however, encouraged that the coroner has identified lessons to be learned to prevent something like this happening again.
“In the coroner’s own words, he said Emily’s death ‘was not only a tragedy to you, I think it was a tragedy for society’.”
They said that they awaited the response from the Transport Secretary “with interest”.
They added: “Nothing can bring our Emily back. We miss her every day.
“We take solace in knowing that her death is not meaningless and we are confident that another family like ours will not go through the same tragedy as we did.”
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