What's been learnt from paddleboard tragedy that claimed four lives?

On a bright October morning nine paddleboarders entered the River Cleddau for an idyllic paddle through the Pembrokeshire town of Haverfordwest.

Just minutes later three were dead and a fourth fatally injured.

On Wednesday their tour leader, former police officer Nerys Bethan Lloyd, 39, from Port Talbot, was sentenced to 10-and-a-half years in prison for causing their deaths.

The judge criticised her "abysmal" approach to health and safety, while an earlier report by the Marine Accident Investigation Branch (MAIB) found the deaths were "tragic and avoidable".

So what went so badly wrong?

And in the three-and-a-half years since the deaths of Paul O'Dwyer, 42, Andrea Powell, 41, Morgan Rogers, 24, and Nicola Wheatley, 40, what has changed to prevent it happening again?

On the day of the tragedy - 30 October 2021 - the group were on a tour run by Lloyd's Salty Dog Co Ltd, based in Port Talbot.

Lloyd was leading the trip alongside her friend and neighbour Paul, a dad-of-three and Army veteran.

Also on the trip was Paul's wife and six paying participants, including Andrea, Nicola and Morgan.

Andrea was a dental hygienist and a mother-of-one, Nicola - a poisons information specialist and toxicologist - had two children and Morgan was an assistant supermarket manager and trainee firefighter.

All four who died were good swimmers.

The group had met up the previous afternoon, stayed overnight at a rented property in Tenby and headed into Haverfordwest that Saturday morning.

Lloyd had established her company in June 2020, initially to sell clothing online, but by May the following year the company began delivering stand-up paddleboard (SUP) rental and training at Aberavon Beach which led to commercial tours.

That fateful Saturday morning the group arrived in a van in Haverfordwest just before 08:00 BST.

Before parking up, Lloyd and Paul stopped off in the town centre to inspect the river.

By about 08:49 everyone from the group was afloat and they set off downriver heading for Burton Ferry, with Lloyd out in front and Paul at the back.

They passed through Haverfordwest town centre five minutes later, with one of the group playing music through a portable speaker.

Minutes later they approached the weir.

Lloyd instructed those close by to follow her and keep to the centre of the river.

At 08:56, kneeling on her SUP, Lloyd slid down the fish pass in the centre of the weir and was swept quickly downriver.

The next participant tried to copy her but was unable to align their SUP with the fish pass and was washed over its right hand side and swept downstream.

Within about a minute, the next six paddleboarders descended the weir.

Andrea was the third paddleboarder to descend, Nicola was the sixth and Morgan was the eighth.

Each of their SUPs pitched forward and they fell into the turbulent water at the foot of the weir.

While the rest of the group was washed clear and swept downstream, Andrea, Nicola and Morgan were sucked into the hydraulic jump, or spin, a recirculating flow similar to a washing machine.

Monitoring from the rear of the group, Paul saw something was wrong, paddled to the right hand side of the river and left the water.

At 08:58, on spotting some of the group were in difficulty, he removed his leash connecting his SUP to his leg, grabbed his SUP and jumped into the river above the weir before being carried over the right hand side of the weir.

At 09:02 a passerby spotted paddleboarders in difficulty in the water and dialled 999.

He then fetched a lifebuoy and repeatedly threw a line to the struggling paddleboarders but none were able to grasp it.

Eight minutes later, emergency services began to arrive at the scene.

A multi-agency response followed involving coastguard rescue teams and helicopter, police, fire and ambulance services, air ambulance and RNLI.

Andrea was recovered from the water close to the weir by members of the public.

She was resuscitated at the scene but died six days later due to injuries caused by drowning.

At Lloyd's sentencing, her husband Mark broke down in tears while describing the agony of seeing his wife in a coma with cuts and bruises to her face and body.

He said the noise their son Finn made when he was told of his mother's death would stay with him forever.

Nicola was recovered from the river by a fellow paddleboarder but died at the scene.

In court her husband Darren said: "I hugged and kissed Nicola goodbye... the next time I would see her would be to identify her body in the mortuary.

"This was not the Nicola that left our house less than 24 hours earlier but it is the face I see every day when I open my eyes."

Morgan's body was recovered by a fellow paddleboarder.

Her mother Theresa told the court the "physical and mental pain that I now live with is too much to bear".

Paul's body was located further downriver by the coastguard helicopter at about 11:00.

In a statement read on behalf of his wife Ceri, she told the court she was "tortured" by what happened and described her husband as the kindest man "with the biggest heart".

Lloyd pleaded guilty to gross negligence manslaughter and was sentenced during a two-day hearing at Swansea Crown Court earlier this week.

On Wednesday, judge Mrs Justice Stacey told her: "You chose to lead the group over a weir in conditions that could not have been more treacherous, placing all of them in extreme danger.

"You did not tell them there would be a weir and you gave them no choice to go over it which inevitably caused this avoidable tragedy and loss of life. Neither you nor Paul were qualified to lead such a tour and your whole approach to health and safety was abysmal."

In December 2022 the MAIB published a report on the tragedy aimed at preventing future incidents. It found:

In February 2023, in response to the MAIB report, Paddle UK (formally British Canoeing) was formally recognised as a national governing body for stand-up paddleboarding by Sport England.

The move was aimed at standardising the consistency and quality of qualifications and safety.

Since 2023 it has partnered with the RNLI to deliver PaddleSafe, a public awareness campaign emphasising safety advice for anyone venturing onto the water.

It has also developed standards for deployment to support volunteers and commercial operators to follow an agreed set of standards.

Paddle UK's director of recreation and development Lee Pooley said it had invested heavily in areas including research around evidence-based safety messaging and were working with manufacturers and retailers to ensure people purchasing paddleboards get safety advice at the point of sale.

Currently there is no mandatory standard for safety advice at the point of sale for SUPs, but Paddle UK said the majority of manufacturers and larger retailers were now collaborating with them to provide consistent and accurate safety messaging.

Paddle UK has also developed an incident reporting system to centrally collect data on incidents and near misses.

It said the British Canoeing Awarding Body (BCAB) was the only regulated and recognised awarding organisation providing dedicated stand-up paddleboard qualifications and awards.

On 2 August 2022, representatives from Dwr Cymru Welsh Water visited Haverfordwest town weir with other stakeholders and commenced a risk assessment of the hazard posed to river users by the weir.

Since the incident, Surf England has published more in-depth stand-up paddle boarding safety advice.

Yes, said Sam Rowlands, Welsh Conservative Member of the Senedd for north Wales and chair of the cross-party group for the outdoor activity sector.

"There are clearly accreditation and assurance schemes in place for these type of activities in Wales, I guess the question now is 'is that enough?' and I think many people are coming to the conclusion perhaps it's not enough," he told BBC Radio Wales Breakfast.

Anyone who provides adventure activities to young people under-18 in return for payment is required to hold a licence under the Adventure Activities Licensing Scheme (AALS), which is administered by the Health and Safety Executive (HSE).

"The question is why is that only for under-18s? Should it also be in place for over-18s?" he added.

Plaid Cymru's Member of the Senedd for mid and west Wales Cefin Campbell also said licensing was an issue.

"We need to tighten up on the licensing of tour operators and outdoor pursuit operators," he said.

When asked, the HSE said it was "considering the circumstances of the incident and any implications for future regulation".

Paddleboarder Clare Rutter from Cardigan in Ceredigion, who had previously paddled with some of those who lost their lives that day, said the tragedy had hit the community hard.

"The paddleboarding community in particular is very tight-knit with no exception in Wales," said the Paddle UK qualified paddlesports instructor.

She said the details of what happened that fateful day in Haverfordwest had "led to much frustration, disappointment and ultimately anger in how things played out".

"Many were shocked and appalled," she said.

"Thoughts of the tragedy are forever in our minds and likely always will be."