Inspectors say it still needs to improve how it investigates patient deaths - but is getting better.
Dad Relives Son's Death In Boat Tragedy
A father has described how his 14-year-old son died in his arms after he became entangled in a propeller having been thrown by a huge wave from their speedboat during a day trip.
Charlie Hutton was travelling on the rigid hull inflatable boat (Rhib) driven by his father Simon and two friends when the incident happened off The Needles landmark off the Isle of Wight on July 20 last year.
Charlie, a keen hockey player whose ambition was to compete in the Olympics, fell into the water along with one of his friends, also aged 14, during the trip.
The group had started at Mudeford in Dorset where the family, from South Croydon, Surrey, have a second home and had been staying for a short holiday.
The friend suffered a serious ankle injury during the incident but was able to get back on the boat.
A third boy, also aged 14, and Mr Hutton, 52, managed to stay on board.
Mr Hutton, a graphic designer, described how he had gone for several trips on the boat with Charlie and his two friends in the days before the accident including water-skiing on the previous day.
Mr Hutton, who had gained Royal Yachting Association training and had been using boats since the age of 12, said he bought the Cobra 6.5 metre Rhib new in June 2010 for #50,000.
He described heading to Alum Bay that afternoon, travelling at about 25-30 knots, when the boat began to be hit by large waves.
He said that the boys, who wore life jackets or buoyancy aids, enjoyed lying towards the front of the boat, hanging on to safety ropes.
Mr Hutton said that the boat was hit by two waves at the side causing him to slow down before it was hit by a large wave at the front.
He said: ''It was choppy but nothing the boat couldn't handle.
''The two came from the side and then the water almost dropped away, it was like there was a big drop and then the wave came over us, it was like a big wall of water.
''I have never come across a wave like it, it engulfed the boat and kept going for a long time.''
Mr Hutton said he believed his son and one of his friends, who had both been at the front of the boat, were washed off the back of the boat.
He said: ''I still can't work out how Charlie got where he got, all I saw was the water, we are talking about literally seconds.''
He described how he found Charlie on top of the propeller.
He said: ''I remember looking back and screaming 'Where's Charlie?'.
''My mind was buzzing, I suddenly realised that what I thought was oil was actually blood.
''There was quite a lot, about 3ft by 3ft.''
He continued: ''Charlie was to the right of the engine, conscious and looking at me, I tried to pull Charlie on to the boat but couldn't.''
He added: ''I saw his head bobbing, he was saying 'Dad, help me'.''
He said that he then cut Charlie's clothing from the propeller and pulled him on to the boat where he performed mouth-to-mouth resuscitation on him.
Mr Hutton said that he could see two wounds at the top of both of his son's legs, one more serious than the other.
He said: ''His eyes were open and he was looking at me.
''I tried to protect his face and told him I loved him, we all loved him.
''I could see Charlie's eyes begin to roll, his breathing became shallow.''
He added: ''I think he died at this point.''
He described how a Coastguard helicopter had responded quickly to his emergency calls and had advised him to carry out the resuscitation but he believed Charlie had died by the time he was airlifted off the boat.
Mr Hutton added: ''I then phoned my wife Gill and said 'I think I have killed Charlie'.''
The inquest heard that Charlie was airlifted to Southampton General Hospital where he was pronounced dead at 5.35pm.
A post-mortem examination showed he died of multiple injuries to his pelvis and left leg.
Mr Hutton and the other two boys, both from Reigate, Surrey, were taken ashore by lifeboat.
The boy, now aged 15, who injured his ankle when falling from the boat said the incident had happened very quickly.
He said: ''It all happened so fast, I just saw this wall of water and everything went white.
''The water was spinning me around, I couldn't see anything.''
Mr Hutton said that he did not feel he had been driving the Rhib, which had a 200 horsepower engine, at excessive speed.
He said: ''If I had hit the waves and bounced back it would have been excessive speed but I had been slowing down.''
The third boy said: ''I had already been to Dorset two times before that trip and I had definitely been quicker than that time so I wasn't uncomfortable with the speed.''
Mr Hutton also said that he had felt the boys' position on the boat was safe.
He said: ''I considered it safe at the time otherwise I wouldn't have let the boys lie there.''
Caroline Sumeray, Isle of Wight coroner, recorded a verdict of accidental death.
She called on the leisure boating industry to promote the use of propeller guards to prevent further similar accidents.
She said: ''He was a very talented and lovely looking boy.
''I am sure there is nothing I can say to ease your pain and suffering.
''You have my deepest sympathies and I hope there will be lessons learnt from Charlie's death.''
Mr Hutton said: ''If there had been a prop guard there my son would probably have survived.
''If I had been aware of them I would probably have had one fitted.''
In a statement released after the incident, Charlie's parents, Simon and Gill Hutton, said: ''We are very sad to announce the death of our beautiful and very talented boy.
''Charlie, who loved the sea and water sports, was a schoolboy at Whitgift in South Croydon.
''His life touched many people and we know school friends will be devastated.
''Two of his closest friends were with him when he died and I hope they remember the great times and laughs we had with Charlie in his final few days in Dorset.
''Charlie was academically bright, an accomplished musician and an amazing field hockey player who had trained with the England under-15 team and had hoped to reach the England under-16 team this year, with the ambition of eventually playing for Britain in the Olympics in 2020.
''His effort, passion and self-belief would surely have taken him there.
''With Ashley Jackson as his hero on the field, we hope that this same passion will help Great Britain win gold this year for Charlie and the country.
''Our thanks go to all those who helped Charlie achieve such an incredible amount.
''We would like to hold a private event for family and friends to celebrate Charlie's life in the autumn when his school returns from the summer holidays.''
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