A mum-of-three died after she fell over the side of a pleasure cruiser and got sucked into the propeller.
Laura Perry had been on her way to comfort her crying son, when the for-hire ship she was on struck a wall, causing her to lose balance and topple over the edge.
A report into the tragedy found that if a better guardrail had been in place, she would have likely not fallen.
The 38-year-old had been on holiday on the Norfolk Broads, on August 19 2020 with a group of nine including her partner, and three sons, aged 16, 14, and four, an inquest heard.
Before they took off in the boat, the family were only given what was called a “cursory” safety video which the Marine Accident Investigation Branch (MAIB) described as “incomplete”.
The group had set off from Ferry Marina boatyard, in Horning, Norfolk, onto the River Bure on their Diamond Emblem cruiser.
On the third day of a five day break, they had been heading out towards Great Yarmouth for “shopping and sightseeing” with Ms Perry’s eldest son at the helm, supervised by his father, The Mail reported.
Ms Perry’s sister took control of the boat and after being informed there was nowhere to moor, she had been turning back before their boat hit an embankment wall.
At the exact moment the boat struck the wall, Ms Perry had been going in to check on her crying child.
The mum was tossed over the edge of the ship, where she became “entangled” in a length of rope and the propeller, and died.
Her partner, James Allen, and her sister jumped in to try and rescue her but she had died “almost instantly” and her body was later recovered by divers.
An inquest is being held into her death and a report from the MAIB found that guardrail inadequate.
According to ITV the report said: “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”.
Norfolk Area coroner Yvonne Blake described the tragedy as the “perfect storm”.
The MAIB report said: "She became entangled in a length of rope and the propeller, suffering multiple injuries that resulted in her drowning.
"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."
